NY Pub Health L § 2807-C (2021)
2021 New York Laws PBH - Public Health Article 28 - Hospitals 2807-C - General Hospital Inpatient Reimbursement for Annual Rate Periods Beginning on or After January First, Nineteen Hundred Eighty-Eight.

§  2807-c.  General  hospital  inpatient reimbursement for annual rate periods  beginning  on  or  after  January   first,   nineteen   hundred eighty-eight.  1.  Payor  payments.  Payments  to  general hospitals for inpatient hospital services provided to persons who are not eligible for payments as beneficiaries of title XVIII of the federal social  security act  (medicare)  shall  be  determined  pursuant  to this section. Payor payments  shall  be  as  follows  unless  an  alternative  reimbursement methodology  is  authorized  in accordance with paragraph (e), (f), (g), (h) or (i) of subdivision four of this section.   * (a) Payments to general hospitals  for  reimbursement  of  inpatient hospital  services  provided  to  patients eligible for payments made by state governmental agencies for patients  discharged  prior  to  January first, two thousand and on and after January first, two thousand; or for patients   discharged   prior   to   January   first,  nineteen  hundred ninety-seven  provided  in   accordance   with   policies   written   by corporations   organized   and  operating  in  accordance  with  article forty-three of the insurance law, or payment by such  a  corporation  on behalf of subscribers of a foreign corporation as described in paragraph (d)   of   subdivision   twelve  of  this  section,  which  provide  for reimbursement on an expense incurred basis; or for  patients  discharged prior  to  January  first,  nineteen  hundred  ninety-seven  provided to subscribers of organizations operating in accordance with the provisions of article forty-four of this chapter, shall be case based payments  per discharge,  for  each  diagnosis-related group established in accordance with paragraph (a) of subdivision  three  of  this  section,  and  shall include:  (i)  a  reimbursable  inpatient operating cost component determined in accordance with subdivision five of this section;  (ii) capital related inpatient expenses determined in accordance  with subdivision eight of this section;  (iii) for patients discharged prior to January first, nineteen hundred ninety-seven  (A)  a  bad  debt and charity care allowance determined in accordance with subdivision fourteen of  this  section,  (B)  a  general health care services allowance determined in accordance with subdivision fourteen-b  of  this  section,  and  (C)  a  bad  debt  and charity care allowance for financially distressed hospitals determined in  accordance with subdivision fourteen-c of this section;  (iv)  a  projection  of  reimbursable inpatient operating costs to the rate year by the trend factor determined in accordance with  subdivision ten of this section; and  (v)  adjustments for any modifications to the case payments determined in accordance with paragraph (a), (b), (c) or (d) of subdivision four of this section.   * NB Effective until December 31, 2023   * (a) Payments to general hospitals  for  reimbursement  of  inpatient hospital  services  provided  to  patients eligible for payments made by state governmental agencies; or provided  in  accordance  with  policies written  by  corporations  organized  and  operating  in accordance with article  forty-three  of  the  insurance  law,  or  payment  by  such  a corporation  on  behalf  of  subscribers  of  a  foreign  corporation as described in paragraph (d) of subdivision twelve of this section,  which provide  for  reimbursement on an expense incurred basis; or provided to subscribers of organizations operating in accordance with the provisions of article forty-four of this chapter, shall be case based payments  per discharge,  for  each  diagnosis-related group established in accordance with paragraph (a) of subdivision  three  of  this  section,  and  shall include:  (i)  a  reimbursable  inpatient operating cost component determined in accordance with subdivision five of this section;  (ii)  capital related inpatient expenses determined in accordance with subdivision eight of this section;  (iii) (A)  a  bad  debt  and  charity  care  allowance  determined  in accordance  with  subdivision  fourteen  of  this section, (B) a general health care services allowance determined in accordance with subdivision fourteen-b of this  section,  and  (C)  a  bad  debt  and  charity  care allowance  for financially distressed hospitals determined in accordance with subdivision fourteen-c of this section;  (iv) a projection of reimbursable inpatient  operating  costs  to  the rate  year by the trend factor determined in accordance with subdivision ten of this section; and  (v) adjustments for any modifications to the case payments  determined in accordance with paragraph (a), (b), (c) or (d) of subdivision four of this section.   * NB Effective December 31, 2023   * (a-1)  Payments  made  by  local  governmental  agencies  to general hospitals for reimbursement of inpatient hospital services  provided  to incarcerated  individuals of local correctional facilities as defined in subdivision sixteen of section two of the correction law shall be at the rates  of  payment  determined  pursuant  to  this  section  for   state governmental  agencies,  excluding  adjustments  pursuant to subdivision fourteen-f of this section.   * NB Effective until December 31, 2023   * (a-1) Payments  made  by  local  governmental  agencies  to  general hospitals  for  reimbursement of inpatient hospital services provided to incarcerated individuals of local correctional facilities as defined  in subdivision sixteen of section two of the correction law shall be at the rates   of  payment  determined  pursuant  to  this  section  for  state governmental agencies.   * NB Effective December 31, 2023   * (a-2) (i) With the exception of  those  enrollees  covered  under  a payment  rate  methodology agreement negotiated with a general hospital, payments for inpatient hospital services provided to  patients  eligible for  medical  assistance pursuant to title eleven of article five of the social services law made by organizations operating in  accordance  with the  provisions  of  article  forty-four  of  this  chapter or by health maintenance organizations organized and  operating  in  accordance  with article  forty-three  of the insurance law shall be the rates of payment that would be paid  for  such  patients  under  the  medical  assistance program,  (i) determined pursuant to this section, excluding adjustments pursuant to subdivision fourteen-f of this section, and  (ii)  excluding medical  education  costs  that  are  reimbursed directly to the general hospital in accordance with paragraph (a-3) of this subdivision.  (ii) Effective July first, two thousand seven, with the  exception  of those  enrollees  covered  under  a  payment  rate methodology agreement negotiated with a  general  hospital,  payment  for  inpatient  hospital services  provided  to  patients  enrolled in the child health insurance program pursuant to title one-A of article twenty-five of  this  chapter made  by  organizations  operating  in accordance with the provisions of article  forty-four  of  this   chapter   or   by   health   maintenance organizations   organized  and  operating  in  accordance  with  article forty-three of the insurance law shall be  the  rates  of  payment  that would  be  paid under the medical assistance program determined pursuant to  this  section,  excluding  adjustments   pursuant   to   subdivision fourteen-f of this section.   * NB Expires December 31, 2023    * (a-3) Notwithstanding any inconsistent provision of law:  (i)  the  commissioner shall establish, subject to the approval of the director of the budget, discrete rates of payment for general  hospitals for  the period July first, nineteen hundred ninety-six through December thirty-first, nineteen hundred ninety-nine  and  periods  on  and  after January  first,  two  thousand for payments under the medical assistance program pursuant to title eleven of article five of the social  services law  for  persons  eligible  for  medical assistance who are enrolled in health maintenance organizations  and  for  payments  under  the  family health  plus  program  for  persons  enrolled  in approved organizations pursuant to title eleven-D of article five of the  social  services  law based on the components of rates of payment established pursuant to this section for persons eligible for medical assistance who are not enrolled in health maintenance organizations for a general hospital for such rate period  that  reflect the estimated reimbursable costs of direct medical education expenses  and  indirect  medical  education  expenses  in  the determination of:  (A)  the  hospital-specific  average  reimbursable inpatient operating cost per discharge pursuant to subdivision six of this section, and  (B) group category average inpatient reimbursable operating  cost  per discharge pursuant to subdivision seven of this section, and  (C)  the  operating  cost  component  of  rates of payment pursuant to paragraphs (f) and (k) of subdivision four of this section, and  (D) the operating cost component of rates  of  payment  in  accordance with paragraphs (e), (g) and (i) of subdivision four of this section for general  hospitals or distinct units of general hospitals not reimbursed on the basis of case based payments per discharge; and  (E) notwithstanding clauses (A) through (D) of this subparagraph,  for periods  on  and  after December first, two thousand nine, the operating cost component of rates of payment subject to subdivision thirty-five of this section, and  (F) notwithstanding clauses (A) through (D) of this subparagraph,  for periods  on  and  after December first, two thousand nine, the operating cost component of rates of payment subject to  paragraphs  (e-1),  (e-2) and  (1)  of  subdivision  four of this section for general hospitals or distinct units of general hospitals not reimbursed on the basis of  case based payments per discharge; and  (ii)  such  rates of payment may be established by the commissioner on any appropriate  payment  basis,  including  a  case  mix  adjusted  per discharge basis.   * NB Expires December 31, 2023   * (b) For patients discharged prior to January first, nineteen hundred ninety-seven,   payments  to  general  hospitals  for  reimbursement  of inpatient hospital services provided to patients eligible  for  payments pursuant  to  the comprehensive motor vehicle insurance reparations act; or enrolled in a self-insured  fund  which  provides  for  reimbursement directly  to  general  hospitals  on an expense incurred basis, with the exception of those enrollees covered under a  payment  rate  methodology agreement  in  accordance  with  the  provisions  of  paragraph  (a)  of subdivision two of this section; or insured under a  commercial  insurer licensed  to  do business in this state and authorized to write accident and health  insurance  and  whose  policy  provides  inpatient  hospital coverage  on  an expense incurred basis; or receiving inpatient hospital services pursuant to an out-of-plan benefits system authorized  pursuant to  section four thousand four hundred six of this chapter, except where such  out-of-plan,  inpatient  hospital  services  are  offered  by   an organization organized pursuant to the not-for-profit corporation law or which meets the qualifications of section 501(c) of the internal revenue  code,   shall   be   case   based   payments  per  discharge,  for  each diagnosis-related group established in accordance with paragraph (a)  of subdivision  three  of  this  section, and equal to the case payments to general  hospitals  provided  in  accordance  with paragraph (a) of this subdivision  for  services  provided  to  subscribers  of   corporations organized  and  operating  in accordance with article forty-three of the insurance  law,  adjusted  for  uncovered  services,  and  increased  by thirteen  percent or, for payments pursuant to the workers' compensation law, the volunteer firefighters' benefit law and the volunteer ambulance workers' benefit law, increased by five percent.  Funds  received  by  a general  hospital  based on the payment differential applied pursuant to this paragraph shall  be  hospital  funds  for  patient  care  purposes. Without  due  cause  general hospitals shall not refuse to accept direct payments from a payor who  would  otherwise  be  eligible  to  reimburse hospitals  for  inpatient services on a case based payment per discharge in accordance with this subdivision.  (b-1) (i) For patients discharged on and after January first, nineteen hundred ninety-seven and prior to January first, two thousand and on and after January first, two thousand, payments  to  general  hospitals  for reimbursement  of  inpatient  hospital  services  provided  to  patients eligible for payments pursuant to the  workers'  compensation  law,  the volunteer  firefighters'  benefit  law, the volunteer ambulance workers' benefit law, and the comprehensive motor vehicle  insurance  reparations act shall be at the rates of payment determined pursuant to this section for  state  governmental  agencies,  excluding  adjustments  pursuant to subdivision fourteen-f of this section and subdivision  thirty-three  of this  section, excluding such further reductions to such payments as are enacted as part of the state budget for the state fiscal year commencing April first, two thousand ten and excluding such further  reductions  to such  payments  as  are  enacted  as  part of the state budget for state fiscal years commencing on and after April first, two thousand eleven.  (ii) The provisions of paragraph (d) of  subdivision  eleven  of  this section  shall  continue to apply to such payors for payments determined pursuant to this paragraph.  (b-2) A payor included in the payor categories specified in  paragraph (a)  or  (b-1)  of  this subdivision shall not be provided the option of payment to a general hospital for inpatient services based on the  lower of  hospital  charges or the case based payment per discharge determined in accordance with this  section  for  a  patient  or  apportioning  the appropriate  case based payment per discharge for a patient by excluding payment for a preexisting condition or acquired condition which  has  to be  treated  along  with  the reason for the admission or, except as may affect qualification for payments in accordance with  paragraph  (b)  or (d) of subdivision four of this section, for days within the inlier stay determined to be medically unnecessary.   * NB Effective until December 31, 2023   * (b)  Payments  to  general  hospitals for reimbursement of inpatient hospital services provided to patients eligible for payments pursuant to the comprehensive motor vehicle insurance reparations act;  or  enrolled in  a  self-insured  fund  which  provides for reimbursement directly to general hospitals on an expense incurred basis, with  the  exception  of those  enrollees  covered  under a payment rate methodology agreement in accordance with the provisions of paragraph (a) of  subdivision  two  of this  section;  or  insured  under  a  commercial insurer licensed to do business in this state and  authorized  to  write  accident  and  health insurance  and  whose  policy provides inpatient hospital coverage on an expense  incurred  basis;  or  receiving  inpatient  hospital   services pursuant  to  an  out-of-plan  benefits  system  authorized  pursuant to  section four thousand four hundred six of  this  chapter,  except  where such   out-of-plan,  inpatient  hospital  services  are  offered  by  an organization organized pursuant to the not-for-profit corporation law or which  meets  the  qualifications  of  section  501  (c) of the internal revenue code, shall be case  based  payments  per  discharge,  for  each diagnosis-related  group established in accordance with paragraph (a) of subdivision three of this section, and equal to  the  case  payments  to general  hospitals  provided  in  accordance  with paragraph (a) of this subdivision  for  services  provided  to  subscribers  of   corporations organized  and  operating  in accordance with article forty-three of the insurance  law,  adjusted  for  uncovered  services,  and  increased  by thirteen  percent or, for payments pursuant to the workers' compensation law, the volunteer firefighters' benefit law and the volunteer ambulance workers' benefit law, increased by five percent.  Funds  received  by  a general  hospital  based on the payment differential applied pursuant to this paragraph shall  be  hospital  funds  for  patient  care  purposes. Without  due  cause  general hospitals shall not refuse to accept direct payments from a payor who  would  otherwise  be  eligible  to  reimburse hospitals  for  inpatient services on a case based payment per discharge in accordance with this subdivision.  A  payor  included  in  the  payor categories  specified  in  this  paragraph  or  in paragraph (a) of this subdivision shall not be provided the option of  payment  to  a  general hospital  for  inpatient services based on the lower of hospital charges or the case based payment per discharge determined  in  accordance  with this  section  for  a patient or apportioning the appropriate case based payment  per  discharge  for  a  patient  by  excluding  payment  for  a preexisting  condition  or  acquired  condition  which has to be treated along with the reason  for  the  admission  or,  except  as  may  affect qualification  for  payments  in accordance with paragraph (b) or (d) of subdivision four of this  section,  for  days  within  the  inlier  stay determined to be medically unnecessary.   * NB Effective December 31, 2023   * (c)  Charge based payments. For patients discharged prior to January first, nineteen hundred ninety-seven, payments to general hospitals  for reimbursement  of inpatient hospital services provided to those for whom a case based payment per discharge system is not authorized by paragraph (a) or (b) of this  subdivision,  or  who  are  not  covered  under  the provisions of paragraph (a) of subdivision two of this section, shall be on  the  basis  of  the hospital's charges; provided, however, for these patients the definition of a short stay patient  pursuant  to  paragraph (d)  of  subdivision four of this section shall apply, and reimbursement to hospitals for  such  patients  shall  be  at  payments  developed  in accordance  with  paragraph  (d)  of  subdivision  four of this section, increased by thirteen percent. The maximum amount to be charged  to  any charge  paying patient for a case shall be one hundred twenty percent of the case based payment per discharge as determined under  paragraph  (b) of  this  subdivision  for  the  diagnosis-related  group with which the patient is identified. Each general hospital shall  establish  a  charge schedule  and  inpatient  charges  from  this  schedule shall be applied uniformly for all inpatient charge based  payments  made  in  accordance with this section.   * NB Effective until December 31, 2023   * (c)  Charge  based  payments.  Payments  to  general  hospitals  for reimbursement of inpatient hospital services provided to those for  whom a case based payment per discharge system is not authorized by paragraph (a)  or  (b)  of  this  subdivision,  or  who  are not covered under the provisions of paragraph (a) of subdivision two of this section, shall be on the basis of the hospital's charges;  provided,  however,  for  these  patients  the  definition  of a short stay patient pursuant to paragraph (d) of subdivision four of this section shall apply,  and  reimbursement to  hospitals  for  such  patients  shall  be  at  payments developed in accordance  with  paragraph  (d)  of  subdivision  four of this section, increased by thirteen percent. The maximum amount to be charged  to  any charge  paying patient for a case shall be one hundred twenty percent of the case based payment per discharge as determined under  paragraph  (b) of  this  subdivision  for  the  diagnosis-related  group with which the patient is identified. Each general hospital shall  establish  a  charge schedule  and  inpatient  charges  from  this  schedule shall be applied uniformly for all inpatient charge based  payments  made  in  accordance with this section.   * NB Effective December 31, 2023  (d)  The  components of rates of payment calculated in accordance with this section related to inpatient operating  costs  shall  be  based  on general   hospital   reimbursable  inpatient  operating  costs  used  in determining payments  for  services  pursuant  to  section  twenty-eight hundred  seven-a  of  this article during the rate period January first, nineteen hundred eighty-seven through  December  thirty-first,  nineteen hundred  eighty-seven  (or  for  a  distinct  unit of a general hospital excluded from case based payments pursuant to paragraph (e)  or  (g)  of subdivision  four  of  this  section  such  distinct  unit  reimbursable inpatient operating costs), excluding inpatient operating costs  related to  services  provided  to  beneficiaries  of title XVIII of the federal social security act (medicare)  in  accordance  with  paragraph  (g)  of subdivision   eleven  of  this  section  and  adjusted  to  reflect  the annualized cost impact of rate revisions or adjustments,  including  the volume  adjustment  and  case  mix  adjustment  for the nineteen hundred eighty-seven rate period, made with  respect  to  such  services,  which shall be defined as a general hospital's or distinct unit's reimbursable inpatient  operating  cost  base;  a  projection to the nineteen hundred eighty-eight rate period by the trend factor  determined  in  accordance with subdivision ten of this section; and an increase to reflect special additional   inpatient  operating  costs  determined  and  allocated  in accordance with paragraph (e) of this subdivision.  (e) General hospital  special  additional  inpatient  operating  costs shall  be determined and allocated among general hospitals in accordance with subparagraphs (i), (iii) and (iv) of this paragraph.  For  purposes of  computing  group  category  average inpatient reimbursable operating costs in accordance with paragraph (a)  of  subdivision  seven  of  this section  and an equivalent cost component for general hospitals that are excluded from the case based payment per diagnosis-related group  system in  accordance  with  paragraph  (e)  or (g) of subdivision four of this section special additional inpatient operating costs  shall  include  an additional  increase determined and allocated among general hospitals in accordance with subparagraph (ii) of this paragraph.  (i) The total cost increases pursuant to  this  subparagraph  for  all general  hospitals  shall in the aggregate be one hundred thirty million dollars for the nineteen hundred eighty-eight  rate  period  to  reflect nineteen  hundred  eighty-five  costs  incurred  in  excess of the trend factor  between  nineteen  hundred  eighty-one  and   nineteen   hundred eighty-five,  such  cost increases to be projected from nineteen hundred eighty-eight to subsequent annual rate periods by the  applicable  trend factor,  and  shall  be  allocated among general hospitals in accordance with the following methodology:   Five hundred dollars per bed shall  be  allocated  to  costs  of  each general  hospital  based on the total number of inpatient beds for which the hospital is certified pursuant to the operating  certificate  issued  for  such  general  hospital  in  accordance  with  section twenty-eight hundred five of this  article  in  effect  on  January  first,  nineteen hundred eighty-eight.   A  factor  of  one  quarter  of  one  percent  of a general hospital's reimbursable inpatient operating cost base as defined in  paragraph  (d) of  this  subdivision,  trended  through  nineteen hundred eighty-eight, shall be allocated to costs of general hospitals for technology advances and a further one  quarter  of  one  percent  of  such  costs  shall  be allocated to costs of general hospitals for increased activities related to quality assurance and patient discharge planning.   The  balance of one hundred thirty million dollars after deducting the dollar value of the per bed cost enhancement and the dollar value of the percentage cost enhancements shall be  allocated  to  costs  of  general hospitals based on the ratio of each general hospital's nineteen hundred eighty-five cost incurred in excess of the trend factor between nineteen hundred  eighty-one  and  nineteen  hundred eighty-five in the following discrete areas, summed, to the total sum of such cost over trend of  all general  hospitals applied to such balance: malpractice insurance costs, infectious and other waste disposal costs, water charges, direct medical education expenses, working capital interest  costs  of  hospitals  that qualified  for  distributions  made  in accordance with paragraph (b) of subdivision sixteen of section  twenty-eight  hundred  seven-a  of  this article,  costs  of  distinct psychiatric units excluded from case based payments per diagnosis-related group, and ambulance costs. For  purposes of  this  subparagraph,  nineteen  hundred  eighty-five cost incurred in excess of the trend  factor  between  nineteen  hundred  eighty-one  and nineteen  hundred eighty-five shall be calculated for each such discrete area based on a general hospital's inpatient  operating  costs  for  the fiscal  year  ending  in  nineteen  hundred eighty-five, after excluding inpatient operating costs related to services provided to  beneficiaries of  title  XVIII of the federal social security act (medicare), for such discrete area in  excess  of  the  hospital's  comparable  component  of reimbursable  inpatient  operating  costs  for its fiscal year ending in nineteen hundred eighty-one, after excluding inpatient  operating  costs related  to  services  provided  to  beneficiaries of title XVIII of the federal social security act (medicare), trended through nineteen hundred eighty-five by the  appropriate  component  of  the  trend  factors  and adjusted  to  reflect  approved  decreases  or  increases  in  inpatient operating costs resulting from all rate adjustments.  (ii) The total additional cost increases pursuant to this subparagraph for all general hospitals  shall  in  the  aggregate  be  forty  million dollars   for  the  nineteen  hundred  eighty-eight  rate  period,  such additional  cost  increases  to  be  projected  from  nineteen   hundred eighty-eight  to  the  rate period by the applicable trend factor, to be allocated among general  hospitals  in  accordance  with  the  following methodology:   The additional increase of forty million dollars shall be allocated to costs  of  general  hospitals  that  are  included  in  group categories established pursuant to paragraph  (b)  of  subdivision  seven  of  this section  based  on  the  ratio  of  the  nineteen  hundred  eighty-eight intermediate group operating costs of each such general hospital, and to costs of general hospitals that are excluded from the case based payment per diagnosis-related group system in accordance with paragraph  (e)  or (g)  of  subdivision  four  of  this  section  based on the ratio of the nineteen hundred eighty-eight intermediate operating costs of each  such general  hospital, to the total sum of such intermediate group operating costs and intermediate operating costs  applied  to  the  forty  million dollars. For purposes of this subparagraph, intermediate group operating  costs of a general hospital shall be calculated in accordance with rules and  regulations adopted by the council and approved by the commissioner based on the reimbursable inpatient operating cost  base  determined  in accordance  with  paragraph  (d)  of  this  subdivision  of such general hospital; adjusted to exclude operating  costs  related  to  specialized hospital  services for which an alternative reimbursement methodology is adopted pursuant to paragraph (e)  or  (g)  or,  if  effective,  (i)  of subdivision  four  of  this section; and trended to the nineteen hundred eighty-eight rate period by the trend factor  determined  in  accordance with  subdivision  ten of this section; and increased to reflect special additional  inpatient  operating  costs  determined  and  allocated   in accordance  with  subparagraph  (i)  of  this paragraph; and adjusted to exclude a factor  for  operating  costs  of  patients  who  required  an alternate  level of care in accordance with paragraph (h) of subdivision four of this section; and adjusted to  exclude  the  components  of  the trended reimbursable inpatient operating cost base related to education, physician,  ambulance services and organ acquisition costs determined in accordance with subparagraphs (i), (iii) and (iv) of  paragraph  (c)  of subdivision  seven  of this section and malpractice insurance costs, and the  components  of  special  additional   inpatient   operating   costs determined  and  allocated  in  accordance with subparagraph (i) of this paragraph associated with cost increases in such costs. For purposes  of this  subparagraph,  intermediate  operating costs of a general hospital excluded from the case based payment per diagnosis-related group  system shall  be calculated in accordance with rules and regulations adopted by the council and approved by the commissioner based on  the  reimbursable inpatient  operating  cost  base determined in accordance with paragraph (d) of this  subdivision  of  such  general  hospital;  trended  to  the nineteen hundred eighty-eight rate period by the trend factor determined in  accordance  with  subdivision  ten of this section; and increased to reflect special additional  inpatient  operating  costs  determined  and allocated  in  accordance  with  subparagraph (i) of this paragraph; and adjusted to exclude  a  factor  for  operating  costs  of  patients  who required  an  alternate  level  of  care  developed  consistent with the provisions of paragraph (h) of subdivision four  of  this  section;  and adjusted to exclude the components of the trended reimbursable inpatient operating  cost base related to education, physician, ambulance services and organ acquisition costs determined consistent with the provisions of subparagraphs (i), (iii) and (iv) of paragraph (c) of subdivision  seven of  this  section and malpractice insurance costs, and the components of special additional inpatient operating costs determined and allocated in accordance with subparagraph (i) of this paragraph associated with  cost increases in such costs.  (iii)  Cost  increases pursuant to this subparagraph shall be made for the nineteen hundred ninety-one rate period to  reflect  cost  increases incurred  in  excess  of  the trend factor and not included in the costs used in determining payments in accordance with paragraph  (d)  of  this subdivision and subparagraphs (i) and (ii) of this paragraph. Such costs shall  in  the  aggregate  be  three hundred twenty-nine million dollars exclusive of costs related to  services  provided  to  beneficiaries  of title  XVIII  of  the federal social security act (medicare). Such costs increases  shall  be  projected  from  nineteen  hundred  ninety-one  to subsequent annual rate periods by the applicable trend factor, and shall be  allocated  among  general  hospitals, except those general hospitals whose base year for determining payments for services in such facilities is nineteen hundred  eighty-seven,  in  accordance  with  the  following methodology:  (A)  Up  to  two hundred twenty-two million dollars shall be allocated for labor adjustments. If the total of the adjustments is less than  two hundred  twenty-two million dollars, then the adjustments shall be fully funded. If the total  of  the  adjustments  is  more  than  two  hundred twenty-two  million dollars, then the adjustment specified in accordance with item (II) of this clause shall be funded at  the  lower  of  twenty percent  of  the  total  amount  allocated  for labor adjustments or its proportional share of the labor adjustments unless the labor  adjustment specified  in item (I) of this clause is less than eighty percent of the total  amount  allocated  for  labor  adjustments  in  which  case   the adjustment  specified  in item (II) of this clause shall be equal to the difference between two hundred twenty-two million dollars and the  total amount of the adjustment specified in item (I) of this clause.  (I)  A  portion of the amount allocated for labor adjustments shall be for labor cost increases related  to  registered  nurses'  salaries  and fringes (twenty percent of salaries) and an add-on for the ripple effect on other health care professionals of at least thirty-five percent. Such adjustment  shall  cover  both  inpatient  and outpatient cost incurred, based on costs reported in a survey conducted by the department for  the period  January  first,  nineteen hundred ninety through June thirtieth, nineteen hundred ninety on  forms  specified  by  the  commissioner  and received  by  the  department  no  later  than  November first, nineteen hundred ninety, annualized, in excess of  nineteen  hundred  eighty-five labor  costs  related to registered nurses' salaries and fringes trended to  nineteen  hundred  ninety  and  the  nineteen  hundred  eighty-eight statewide  nurse salary adjustment trended to nineteen hundred ninety by the appropriate components of the trend factors adjusted to reflect  the effect  of  the  annualization  of  nineteen hundred ninety data and the result trended  to  nineteen  hundred  ninety-one  and  shall  be  based exclusively  on  regional experience. Such regional adjustment shall not be less than zero.  Each  individual  hospital  within  a  region  shall receive  a  portion of the regional adjustment equal to its share of the total inpatient and outpatient  reimbursable  operating  costs  for  the region  excluding costs related to services provided to beneficiaries of title XVIII of the federal social security act (medicare) and  excluding direct medical education costs.  (II)  A portion of the amount allocated for labor adjustments shall be for personnel costs other  than  those  related  to  registered  nurses' salaries  and  fringes  and  the  ripple  effect  on  other  health care professionals. Such adjustment shall cover both inpatient and outpatient costs incurred, based on costs reported in a  survey  conducted  by  the department for the period January first, nineteen hundred ninety through June  thirtieth,  nineteen  hundred  ninety  on  forms  specified by the commissioner and received by  the  department  no  later  than  November first,  nineteen  hundred  ninety,  annualized,  in  excess  of nineteen hundred eighty-five personnel costs covered by this  adjustment  trended to  nineteen hundred ninety and the annualized rate adjustments approved in nineteen hundred eighty-nine for  personnel  costs  covered  by  this adjustment  for  increased  hospital  costs  to  meet  additional  state requirements  that  became  effective  July  first,   nineteen   hundred eighty-nine  trended  to  nineteen  hundred  ninety  by  the appropriate components of the trend factors adjusted to reflect the  effect  of  the annualization  of nineteen hundred ninety data and the result trended to nineteen hundred ninety-one and shall be based exclusively  on  regional data.  (III)  In  the  event that federal financial participation in payments made for beneficiaries eligible for medical assistance under  title  XIX of  the  federal  social  security  act  based  upon  the allocation and  adjustment specified in items (I) and (II) of  this  clause  related  to outpatient  costs as a component of such payments is not approved by the federal government then such outpatient costs shall not be considered in calculating such adjustment.  (C)  Thirty-three  million  dollars  shall be allocated for technology advances and changes in medical practice. A fixed amount per  bed  shall be  allocated  to  the costs of each general hospital based on the total number of inpatient beds for which the  general  hospital  is  certified pursuant  to  the operating certificate issued for such general hospital in accordance with section twenty-eight hundred five of this article  in effect on June thirtieth, nineteen hundred ninety.  (D)  Thirty-four  million  dollars shall be allocated to those general hospitals providing comprehensive health care to  the  communities  they serve as determined by the commissioner pursuant to regulations approved by  the  council.  Comprehensive  health  care includes providing and/or accommodating patients' health care needs at the appropriate levels  and settings  of care, and reaches outside of traditional inpatient services to outpatient and other services. Factors to be considered  in  deciding which  general hospitals are providing comprehensive health care and the size of the adjustment shall include but not be limited to:  clinic  and emergency room volume compared to inpatient volume (measured using total volume   and/or  volume  related  to  medicaid  and  medically  indigent patients); number and type of clinic services offered;  availability  of services;  whether  the  general  hospital is an AIDS designated center, prenatal care assistance program provider, home  health  care  provider, trauma center, burn center; whether the general hospital offers neonatal intensive  care  services,  dialysis  services,  birthing  center backup agreements, AIDS outpatient programs, specific mental health,  drug  and alcohol  programs  including outpatient and emergency services and those designated pursuant to section 9.39  of  the  mental  hygiene  law;  and whether  the  general  hospital's  emergency room is designated as a 911 receiving hospital. In the event that federal financial participation in payments made for beneficiaries eligible for  medical  assistance  under title  XIX  of the federal social security act based upon the adjustment specified in this clause as a component of such payments is not approved by the  federal  government  because  of  the  inclusion  of  outpatient services  then  such  outpatient  services  shall  not  be considered in calculating such adjustment. If such exclusion results in the allocation for this adjustment not being spent, then any unspent portion  shall  be reallocated to further fund the adjustments specified in clauses (D) and (E)  of  this  subparagraph  in  the  same  proportion as their original funding.  (E)(I) Twenty-six million dollars shall be allocated to the  costs  of general hospitals based on the ratio of each general hospital's nineteen hundred  eighty-nine cost incurred in excess of the trend factor between nineteen hundred eighty-five and nineteen  hundred  eighty-nine  in  the certain discrete areas, summed, to the total sum of such cost over trend of  all  general  hospitals  applied  to  the  total  funds  under  this allocation. Such discrete cost areas shall include but  not  be  limited to:  infectious  and  other waste disposal costs, universal precautions, working capital interest costs, costs for asbestos removal, costs of low osmolality contrast media, malpractice costs, water and  sewer  charges, ambulance costs and costs related to designation as a trauma center. For purposes  of  this clause, nineteen hundred eighty-nine cost incurred in excess of the trend factor  between  nineteen  hundred  eighty-five  and nineteen  hundred eighty-nine shall be calculated for each such discrete area based on a general hospital's inpatient  operating  costs  for  the fiscal  year  ending  in  nineteen  hundred eighty-nine, after excluding  inpatient operating costs related to services provided to  beneficiaries of  title  XVIII of the federal social security act (medicare), for such discrete area in  excess  of  the  hospital's  comparable  component  of reimbursable  inpatient  operating  costs  for its fiscal year ending in nineteen hundred eighty-five, after excluding inpatient operating  costs related  to  services  provided  to  beneficiaries of title XVIII of the federal social security act (medicare), trended through nineteen hundred eighty-nine by the  appropriate  component  of  the  trend  factors  and adjusted  to  reflect  approved  decreases  or  increases  in  inpatient operating costs resulting from all rate adjustments.  (II) Any  funds  allocated  under  this  clause  and  not  distributed pursuant  to  item  (I)  of  this  clause  shall  be  allocated  for the following: to reimburse for a portion of  the  cost  increases  incurred above  the trend factor between nineteen hundred eighty-one and nineteen hundred eighty-five for those discrete cost areas specified in the  last paragraph  of  subparagraph  (i) of paragraph (e) of this subdivision as added by chapter two of the laws of nineteen  hundred  eighty-eight  and not  reimbursed  in  accordance with such paragraph. Such funds shall be allocated to general hospitals in the same manner as specified  in  such paragraph.  (F)  Seven  million two hundred thousand dollars shall be allocated to account for the increase in the number of patients admitted through  the emergency  room  and  the high costs of treating such patients which has resulted in an increase in severity  within  diagnosis  related  groups. Such funds shall be allocated to general hospitals based on the nineteen hundred  eighty-nine  hospital-specific  data  on  increased  admissions through the emergency room since nineteen hundred eighty-one,  excluding those admissions related to providing services to beneficiaries of title XVIII of the federal social security act (medicare).  (G)  Two hundred fifty dollars per bed shall be allocated to the costs of each general hospital having two hundred or less certified acute care beds and classified as a rural  hospital  for  purposes  of  determining payment  for  inpatient acute care services provided to beneficiaries of title XVIII of the federal social security act (medicare) or under state regulations, for recruiting and retaining health care  personnel,  based on  the total number of inpatient acute care beds for which such general hospital is certified pursuant to the operating certificate  issued  for such  general  hospital  in accordance with section twenty-eight hundred five of this article in  effect  on  June  thirtieth,  nineteen  hundred ninety.  (H) One million dollars shall be allocated to assist general hospitals involved in a merger, acquisition, or consolidation in meeting the costs associated  with  such merger, acquisition, or consolidation on or after January first, nineteen hundred ninety-one. The commissioner shall  make rate adjustments for such allocations.  (I)   Five   hundred   thousand  dollars  shall  be  allocated  for  a practitioner placement  program  to  assist  general  hospitals  in  the placement  of physicians and other health care practitioners to practice primary health care and/or dentistry in underserved areas, to serve  the medically  needy, and including services with affiliated community based providers.  The  commissioner  shall  make  rate  adjustments  for  such allocations.   Notwithstanding   any   inconsistent  provision  of  this subdivision, this clause shall not apply in rate periods  commencing  on or after January first, nineteen hundred ninety-four.  (iv)  Cost  increases  pursuant to this subparagraph shall be made for the nineteen hundred ninety-four rate period to reflect  cost  increases incurred  in  excess  of  the trend factor and not included in the costs used in determining payments in accordance with paragraph  (d)  of  this  subdivision  and  subparagraphs  (i),  (ii) and (iii) of this paragraph. Such costs shall in the aggregate be one hundred  seventy-three  million dollars exclusive of costs related to services provided to beneficiaries of  title XVIII of the federal social security act (medicare). Such cost increases shall  be  projected  from  nineteen  hundred  ninety-four  to subsequent annual rate periods by the applicable trend factor, and shall be  allocated  among  general hospitals in accordance with the following methodology:  (A) Forty-six million dollars shall  be  allocated  to  the  costs  of general  hospitals  for  treating  tuberculosis  patients.  Each general hospital shall receive a portion of this total equal to its share of the statewide total of inpatient tuberculosis discharges based on  the  most recent twelve month period for which data is available.  (B)   Sixty-three   million  dollars  shall  be  allocated  for  labor adjustments in accordance with the following methodology:  (I) Fifty-five million dollars  shall  be  for  labor  cost  increases incurred  prior  to  June thirtieth, nineteen hundred ninety-three. Each general hospital shall receive a portion of  this  total  equal  to  its share  of  the  statewide total of inpatient and outpatient reimbursable operating costs based on nineteen hundred ninety  data  excluding  costs related  to  services  provided  to  beneficiaries of title XVIII of the federal social security act  (medicare)  and  excluding  direct  medical education costs.  (II)  Eight  million  dollars  of the amount to be allocated for labor adjustments pursuant to this clause  shall  be  distributed  to  general hospitals located in the counties of Ulster, Sullivan, Orange, Dutchess, Putnam,  Rockland,  Columbia,  Delaware  and Westchester, to account for prior disproportionate  increases  in  unreimbursed  labor  costs.  Each individual hospital shall receive a portion of the eight million dollars equal  to  its  share of the total inpatient and outpatient reimbursable operating costs based on nineteen hundred ninety data for all  hospitals located  in  the  above-referenced  counties  excluding costs related to services provided to beneficiaries of title XVIII of the federal  social security act (medicare) and excluding direct medical education costs.  (C)  Fifty-five  million  dollars  shall  be allocated to the costs of increased  activities  related  to  regulatory   compliance,   universal precautions  and  infection  control  related to AIDS, tuberculosis, and other infectious diseases, including  the  training  of  employees  with regard to infection control, and for infectious and other waste disposal costs.  A  fixed  amount per bed shall be allocated to the costs of each general hospital based on the total number of inpatient beds  for  which the  general hospital is certified pursuant to the operating certificate issued for each general hospital in accordance with section twenty-eight hundred five of this article in effect on August twenty-fourth, nineteen hundred ninety-three.  (D) Three million dollars shall be allocated as follows:  (I) Two hundred fifty dollars per bed shall be allocated to the  costs of each general hospital having two hundred or less certified acute care beds  and  classified  as  a  rural hospital for purposes of determining payment for inpatient services provided to beneficiaries of title  XVIII of   the   federal   social  security  act  (medicare)  or  under  state regulations, in recognition  of  the  unique  costs  incurred  by  these facilities  in  complying  with  state  regulations,  based on the total number of inpatient acute care beds for which such general  hospital  is certified  pursuant to the operating certificate issued for such general hospital in accordance with section twenty-eight hundred  five  of  this article   in   effect   on   August   twenty-fourth,   nineteen  hundred ninety-three.  (II) The remainder shall be allocated on a proportional basis  to  the costs  of  each  general  hospital  classified  as  a rural hospital for purposes of determining  payment  for  inpatient  services  provided  to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare)  or  under  state  regulations,  in recognition of the unique costs incurred by these  facilities  to  provide  hospital  services  in remote   or   sparsely  populated  areas,  according  to  the  following methodology:  (1) the net income, or the net loss expressed  as  a  negative,  as  a proportion  of  the net patient revenue, of each such hospital, based on operating results for the nineteen hundred ninety and  nineteen  hundred ninety-one  rate years, shall be computed and averaged, and expressed as a percentage;  (2) each such resulting percentage average shall be multiplied by each such hospital's number of inpatient beds  for  which  such  hospital  is certified pursuant to the operating certificate issued for such hospital in  accordance  with  section  two  thousand  eight hundred five of this article in effect on June thirtieth, nineteen hundred ninety,  and  such resulting  products for all such hospitals shall be summed, and such sum shall be divided by the total of all such beds for all  such  hospitals, and the resulting quotient shall be the weighted average rural operating margin expressed as a percentage; and  (3) one percentage point shall be subtracted from each such hospital's average  net  operating  margin,  and  the resulting difference shall be divided by the weighted average rural operating margin; and  (4) (a) if the quotient resulting  from  the  computation  in  subitem three  above is less than zero, then the absolute value of such quotient shall be multiplied by each such hospital's number of inpatient beds for which such hospital is certified pursuant to the  operating  certificate issued  for  such hospital in accordance with section two thousand eight hundred five of this chapter  in  effect  on  June  thirtieth,  nineteen hundred  ninety,  such  product shall be multiplied by one hundred fifty dollars, and such resulting amount shall be such  hospital's  adjustment pursuant to this clause;  (b)  if  the  quotient resulting from the computation in subitem three above is zero or greater, such hospital's adjustment  pursuant  to  this clause shall be zero; and  (c)  provided,  however,  that if the total of all such adjustments so computed exceeds the amount to be  allocated  in  accordance  with  this item, each such hospital's adjustment shall be proportionately reduced.  (E)  Three  million  dollars  shall  be  allocated  to  assist general hospitals involved in a merger, acquisition, or consolidation in meeting the costs associated with such merger, acquisition, or consolidation  on or  after  January first, nineteen hundred ninety-four. The commissioner shall make rate adjustments for such allocations.  (F) (I) One million five hundred thousand dollars shall  be  allocated for  enhanced  rates  for general hospitals participating within a rural health network as defined in  subdivision  two  of  section  twenty-nine hundred  fifty-one  of  this  chapter.  Such  rate enhancements shall be established only for  inpatient  services  provided  by  such  hospitals through  the written rural health network agreement, where such services have  been  approved   for   enhanced   rates   by   the   commissioner. Notwithstanding  any  inconsistent provision of law, such enhanced rates shall be subject to the availability of federal financial  participation pursuant to title XIX of the federal social security act in expenditures made  for  eligible  patients, including pooling arrangements and volume adjustments, provided, however that such enhanced rates shall not affect the calculation for any  other  general  hospital  of  the  group  price  component  calculated  pursuant  to subparagraph (i) of paragraph (a) of subdivision seven of this section.  (II)  One million five hundred thousand dollars shall be allocated for enhanced rates for general  hospitals  participating  within  a  central services  facility  rural health network as defined in subdivision three of section twenty-nine hundred fifty-one  of  this  chapter.  Such  rate enhancements  shall  be established only for inpatient services provided by such hospitals through  the  network  operational  plan,  where  such services  have  been  approved  for  enhanced rates by the commissioner. Notwithstanding any inconsistent provision of law, such  enhanced  rates shall  be subject to the availability of federal financial participation pursuant to title XIX of the federal social security act in expenditures made for eligible patients, including pooling  arrangements  and  volume adjustments, provided, however that such enhanced rates shall not affect the  calculation  for  any  other  general  hospital  of the group price component calculated pursuant to subparagraph (i) of  paragraph  (a)  of subdivision seven of this section.  (f)  The  commissioner  and  the  state  director  of the budget shall consider  providing  a  supplementary  increase  to   general   hospital reimbursable  inpatient  operating costs for purposes of computing rates of payment for annual rate periods beginning on or after January  first, nineteen  hundred  eighty-nine  in  accordance  with  this  section  for reasonable  and  necessary  supplementary  cost  increases  in   general hospital  operating  costs  for  such  rate  period  or periods based on increased minimum standards and procedures relating to general  hospital operating  certificates  adopted  by  the  council  and  approved by the commissioner or state initiatives related to recruitment or  maintenance of  an appropriate level of personnel providing professional services to patients. Any such supplementary increase shall be allocated to costs of general hospitals in accordance with rules and  regulations  adopted  by the council and approved by the commissioner.  (g)  Hospital discharges for purposes of computing case based payments per discharge pursuant to this section shall be based on the  number  of patient  discharges  during the rate period from January first, nineteen hundred eighty-seven through  December  thirty-first,  nineteen  hundred eighty-seven excluding discharges of beneficiaries of title XVIII of the federal  social  security  act  (medicare)  and  adjusted as provided in specific provisions of this section,  or  the  number  of  such  patient discharges during a recent twelve month period prior thereto established by regulation for which data are available subsequently reconciled by an adjustment to reflect nineteen hundred eighty-seven discharge data.   * (h)  Notwithstanding  any  inconsistent  provision  of this section, commencing April first, nineteen hundred ninety-five:  (i) rates of payment for patients eligible for payments made by  state governmental agencies shall be reduced by the commissioner to reflect an exclusion  from  reimbursable inpatient operating costs commencing April first, nineteen hundred ninety-five of the special additional  inpatient operating  costs  determined  and  allocated  among general hospitals in accordance with clause (C) of  subparagraph  (iii)  and  clause  (C)  of subparagraph (iv) of paragraph (e) of this subdivision and the factor of one  quarter of one percent of general hospitals' reimbursable inpatient operating  cost  base  allocated  to  costs  of  general  hospitals  for technology advances in accordance with subparagraph (i) of paragraph (e) of this subdivision; and  (ii)  general hospitals may not request and the commissioner shall not consider any pending or further appeals for an adjustment  to  rates  of payment  based  on costs associated with technology advances and changes in medical practice  and  such  adjustments  to  reimbursable  inpatient  operating costs pursuant to clause (C) of subparagraph (iv) of paragraph (e) of this subdivision.  (iii)  Notwithstanding  the  foregoing, or any other provision of this section, the commissioner may establish pass through payments, or  other appropriate  methodologies, for the period ending December thirty-first, two thousand three for innovative medical device advances for which  the federal  centers  for medicare and medicaid services adopts new codes to the hospital inpatient prospective payment system prior to  the  federal food and drug administration's approval of such medical device.   * NB Expired March 31, 2011  (i)  For  the rate period July first, two thousand seven through March thirty-first, two thousand eight and for rates applicable to  the  state fiscal  year  commencing April first, two thousand eight, and each state fiscal year thereafter through March thirty-first,  two  thousand  nine, and  for  the  period  April  first,  two thousand nine through November thirtieth, two thousand nine, provided, however,  that  for  the  period April  first, two thousand nine through November thirtieth, two thousand nine the aggregate rate adjustments calculated pursuant to  subparagraph (ii)  of  this  paragraph  shall  not  exceed  four million dollars, and contingent upon the availability of federal financial participation:  (i) The commissioner shall adjust inpatient medical  assistance  rates of  payment  calculated  pursuant  to  this section for public hospitals other  than  non-state  public  hospitals  located  in  a  city  with  a population  of  more  than  one  million persons, that meet the targeted medicaid discharge percentage in accordance  with  the  methodology  set forth  in  subparagraph  (ii)  of  this  paragraph. For purposes of this paragraph, "targeted medicaid discharge percentage" shall mean  that  at least  seventeen  and  one-half  percent  of  a  public hospital's total discharges  were  patients  eligible  for  payments  under  the  medical assistance  program  pursuant  to  title  eleven  of article five of the social services law, including  those  enrolled  in  health  maintenance organizations,  and  patients  eligible  for  payments  under the family health plus program pursuant to title eleven-D of article  five  of  the social   services  law,  based  on  data  reported  in  such  hospital's institutional cost report submitted for the two thousand four period and filed with the department by  November  first,  two  thousand  six.  Any hospital that meets the filing deadline shall have until June first, two thousand  seven  to  submit revised and corrected data schedules in such institutional  cost  report  which  established  eligibility  for   such adjusted rate.  (ii)  The  aggregate amount of rate adjustments calculated pursuant to this paragraph shall not  exceed  six  million  dollars  for  each  rate period.  Such  amount  shall  be  allocated  proportionally based on the relative numbers of medicaid discharges  among  those  public  hospitals eligible  for  rate  adjustments  in accordance with subparagraph (i) of this paragraph based on each such hospital's reported medical assistance data specified in subparagraph (i) of this paragraph. Such amounts shall be included as an  add-on  to  medical  assistance  inpatient  rates  of payment,  excluding  exempt  unit  rates, and shall not be reconciled to reflect changes in medical assistance utilization between  two  thousand four and the current rate year.  (j)  For  the rate period July first, two thousand seven through March thirty-first, two thousand eight and for rates applicable to  the  state fiscal  year  commencing April first, two thousand eight, and each state fiscal year thereafter through March thirty-first, two thousand nine and for  the  period  April  first,  two  thousand  nine  through   November thirtieth,  two  thousand  nine,  provided, however, that for the period April first, two thousand nine through November thirtieth, two  thousand  nine  the aggregate rate adjustments calculated pursuant to subparagraph (ii) of this paragraph shall not exceed  twenty-eight  million  dollars, and contingent upon the availability of federal financial participation:  (i)  The  commissioner shall adjust inpatient medical assistance rates of payment calculated pursuant to this section for  voluntary  hospitals other  than  voluntary  hospitals located in a city with a population of more than one million persons that meet the targeted medicaid  discharge percentage  in accordance with the methodology set forth in subparagraph (ii) of this  paragraph.  For  purposes  of  this  paragraph,  "targeted Medicaid discharge percentage" shall mean between seventeen and one-half percent   and  thirty-five  percent  of  a  voluntary  hospital's  total discharges  were  patients  eligible  for  payments  under  the  medical assistance  program  pursuant  to  title  eleven  of article five of the social services law, including  those  enrolled  in  health  maintenance organizations,  and  patients  eligible  for  payments  under the family health plus program pursuant to title eleven-D of article  five  of  the social   services  law,  based  on  data  reported  in  such  hospital's institutional cost report submitted for the two thousand four period and filed with the department by  November  first,  two  thousand  six.  Any hospital that meets the filing deadline shall have until June first, two thousand  seven  to  submit revised and corrected data schedules in such institutional  cost  report  which  established  eligibility  for   such adjusted rate.  (ii)  The  aggregate amount of rate adjustments calculated pursuant to this paragraph shall not exceed forty-two million dollars for each  rate period.  Such amount shall be allocated proportionally based on relative numbers of medicaid discharges among those voluntary hospitals  eligible for  rate  adjustments  in  accordance  with  subparagraph  (i)  of this paragraph based on each such hospital's reported medical assistance data specified in subparagraph (i) of this paragraph. Such amounts  shall  be included  as an add-on to medical assistance inpatient rates of payment, excluding exempt unit rates, and shall  not  be  reconciled  to  reflect changes  in medical assistance utilization between two thousand four and the rate year.  (k) Subject to the availability of  federal  financial  participation, the  commissioner shall adjust inpatient rates of payment for non-public general hospitals located in a city with a population of more  than  one million  persons  for the following periods and in the following amounts in order to ensure meaningful access  to  the  hospital's  services  and reasonable  accommodation for all medicaid patients who require language assistance:  (i) for the period July first, two  thousand  seven  through  December thirty-first,  two thousand seven, thirty-eight million dollars shall be allocated proportionally to such hospitals based  on  fifty  percent  of each  such  hospital's reported general clinic medicaid visits and fifty percent on each such hospital's reported medicaid inpatient  discharges, as  reported  in  each  hospital's  two thousand four institutional cost report, as submitted to the department  prior  to  November  first,  two thousand six, to the total of all such general clinic visits reported by all such hospitals.  (ii)  for  the  period  April  first, two thousand eight through March thirty-first, two thousand nine, and each state fiscal  year  thereafter through  November  thirtieth,  two  thousand  nine, thirty-eight million dollars shall be allocated on an annualized basis for  such  purpose  to such   hospitals  in  accordance  with  the  methodology  set  forth  in subparagraph (i) of  this  paragraph,  provided,  however,  that  thirty percent  of  such  funds shall be allocated proportionally, based on the number of foreign languages utilized by  one  or  more  percent  of  the  residents  in  each  hospital  total  service area population, provided, however, that for the period April  first,  two  thousand  nine  through November  thirtieth, two thousand nine, such allocation shall be reduced to twenty-five million three hundred thirty-three thousand dollars.  (l)  Effective for periods on and after July first, two thousand seven through November thirtieth, two thousand nine:  (i) Subject to the availability of  federal  financial  participation, the  commissioner  shall  adjust  inpatient  medical assistance rates of payment calculated  pursuant  to  this  section  for  general  hospitals located  in  the  counties  of Nassau and Suffolk in accordance with the methodology set forth  in  subparagraph  (ii)  of  this  paragraph.  For purposes  of  this paragraph, "medicaid inpatient discharges" shall mean the total  number  of  such  general  hospital's  discharges  where  the patients were eligible for payments under the medical assistance program pursuant  to  title  eleven  of article five of the social services law, including  those  enrolled  in  health  maintenance  organizations,  and patients  eligible  for  payments  under  the family health plus program pursuant to title eleven-D of article five of the social  services  law, based  on  data  reported  in  such hospital's institutional cost report submitted for the two thousand four period and filed with the department by November first, two thousand six.  (ii) The amount  of  rate  adjustments  calculated  pursuant  to  this paragraph  shall  not  exceed  five  million  dollars  in  the aggregate annually. Such amount shall be allocated  proportionally  based  on  the relative  numbers  of  medicaid discharges among those general hospitals eligible for rate adjustments in accordance  with  subparagraph  (i)  of this paragraph based on each such hospital's reported medical assistance data specified in subparagraph (i) of this paragraph. Such amounts shall be  included  as  an  add-on  to  medical  assistance inpatient rates of payment, excluding exempt unit rates, and shall  not  be  reconciled  to reflect  changes  in medical assistance utilization between two thousand four and the current rate year.   2. Special payment rate methodology agreements, negotiated rates.  (a) Any payment rate methodology agreement negotiated between a self-insured and  self-administered  fund  and  a  specific  general  hospital or its successor which was in effect on May first, nineteen hundred eighty-five shall be permitted to continue with such fund,  or  a  self-insured  and self-administered  fund related in interest to such fund through merger, consolidation or  corporate  reorganization  subsequent  to  May  first, nineteen   hundred   eighty-five,  as  long  as  any  revision  to  such methodology does not provide more of an economic advantage to  the  fund than  the  previous  agreement.  A  general  hospital which has any such agreement shall file with the commissioner  information  regarding  each such agreement, as may be required by regulations adopted by the council and approved by the commissioner.  (b)(i)  Nothing  in  this  section shall prohibit the establishment of special payment  rate  methodologies  in  arrangements  between  general hospitals  and  health maintenance organizations operating in accordance with the provisions of article  forty-three  of  the  insurance  law  or article  forty-four  of this chapter, provided the commissioner has been notified  of  the  proposed  arrangement,  has  reviewed  such  proposed arrangement  and has issued his written approval of the arrangement. The commissioner shall not approve such an arrangement if it would result in payments to a  general  hospital  for  inpatient  services  provided  to subscribers  of  health maintenance organizations which in the aggregate are less than what otherwise would have been paid under  the  provisions of this section, unless the health maintenance organization demonstrates that  such  lower  payments  are  justified because the arrangement will  result in  lower  costs  to  the  general  hospital,  and  the  payments approximate costs. Such arrangements may be approved by the commissioner to:  integrate  the medical delivery functions of the health maintenance organization  with  the  medical  delivery  functions  of  the hospital, including  but  not  limited   to   joint   staffing   arrangements   or pre-admission  testing  arrangements; or integrate the method of payment and financial incentives to the hospital with the method of payment  and financial  incentives  to  physicians  or  other providers in the health maintenance  organization;  or  integrate  the  method  of  payment  and financial  incentives  to  the  hospital  with  the  health  maintenance organization, including, but not limited to, bed leasing  or  capitation payments.  Notwithstanding  any  inconsistent provision of this section, for periods beginning  on  or  after  January  first,  nineteen  hundred ninety-four,    negotiated   agreements   between   health   maintenance organizations  and  general  hospitals  which  were  approved   by   the commissioner and which were in effect on December thirty-first, nineteen hundred ninety-three, may continue.  (ii)  Notwithstanding  any  inconsistent  provisions  of this section, health  maintenance  organizations  operating  in  accordance  with  the provisions  of  article  forty-three  of  the  insurance  law or article forty-four of this chapter,  having  enrollees  eligible  for  inpatient general hospital payments as beneficiaries of title XVIII of the federal social  security  act  (medicare)  shall reimburse general hospitals for inpatient services for these enrollees in accordance with the provisions contained in title XVIII of the federal social security act (medicare).  (c) Special payment  rate  methodology  agreements  other  than  those permitted in accordance with the provisions of paragraphs (a) and (b) of this subdivision shall not be authorized, and no other arrangements with a  general  hospital  for  inpatient  rates  of payment other than those established in accordance with this section shall be negotiated.   * (d)  Notwithstanding  any  inconsistent  provision   of   law,   the provisions  of paragraphs (a), (b) and (c) of this subdivision shall not apply to payments for patients discharged on  or  after  January  first, nineteen hundred ninety-seven.   * NB Expires December 31, 2023   3.  Diagnosis-related  groups  and weights. (a) The commissioner shall establish as a basis for case classification for  case  based  rates  of payment  the  same system of diagnosis-related groups for classification of hospital discharges as established for purposes of  reimbursement  of inpatient hospital service pursuant to title XVIII of the federal social security  act  (medicare) in effect on the first day of July in the year preceding the rate period. However, the  council  may  adopt  rules  and regulations, subject to the approval of the commissioner, to adjust such diagnosis-related   groups  or  establish  additional  diagnosis-related groups to reflect subsequent revisions applicable to  reimbursement  for discharges  of  beneficiaries  of  title  XVIII  of  the  federal social security act (medicare) effective subsequent to the first day of July in the year preceding the rate period, or to identify medically appropriate patterns of health resource use efficiently and  economically  provided. No  such  regulations,  however,  except  those  to  reflect  subsequent revisions applicable to reimbursement for discharges of beneficiaries of title XVIII of the federal social security act (medicare) or for changes made to diagnosis-related groups for neonatal services and  services  to acquired  immune  deficiency syndrome (AIDS) patients shall apply to the rate period beginning January first, nineteen hundred eighty-eight.  For subsequent   rate  periods  regulations  other  than  those  to  reflect subsequent revisions  applicable  to  reimbursement  for  discharges  of beneficiaries  of  title  XVIII  of  the  federal  social  security  act  (medicare) may in addition apply to  changes  to  the  diagnosis-related groups  for  other  services,  including  but  not limited to, pediatric services;  provided,  however,  that  psychiatric   and   rehabilitation services shall not be included.   Notwithstanding section one hundred twelve or one hundred seventy-four of  the  state  finance  law or any other law, rule or regulation to the contrary, the commissioner  may  contract  with  a  vendor  for  nominal consideration   to  develop  the  specifications  for  the  adjusted  or additional diagnosis-related groups if the commissioner certifies to the comptroller that such contract is in the best interest of the health  of the  people of the state. Notwithstanding that such specifications shall be available pursuant to article six of the public  officers  law,  such contract  may  provide  that  the  specifications  for  such adjusted or additional diagnosis-related groups provided  by  the  vendor  shall  be subject to copyright protection pursuant to federal copyright law.  (b)  The  methodology  for  assignment  of  patient  discharges within diagnosis-related groups applicable for purposes of determining payments for discharges of beneficiaries of title XVIII  of  the  federal  social security  act  (medicare) in effect on the first day of July in the year preceding the rate period, revised to reflect such adjustments as may be made to the diagnosis-related group classification  system  pursuant  to paragraph  (a)  of this subdivision, shall be applied to assign specific patient  discharges  within  the  diagnosis-related  groups  established pursuant  to  paragraph  (a)  of this subdivision. The council may adopt rules and regulations, subject to the approval of the  commissioner,  to revise the methodology for the assignment of specific patient discharges within   the  diagnosis-related  groups  to  reflect  revisions  to  the methodology  applicable  for  purposes  of  determining   payments   for discharges  of  beneficiaries  of  title  XVIII  of  the  federal social security act (medicare) effective subsequent to the first day of July in the year preceding the rate period.   * (c) (i) The commissioner shall determine  an  appropriate  weighting factor  for  each  diagnosis-related  group  which reflects the relative general  hospital  resources  used   by   all   patients,   other   than beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare),  with  respect  to   discharges   classified   within   that diagnosis-related  group  compared to discharges classified within other diagnosis-related groups. For rate periods  during  the  period  January first,  nineteen  hundred  eighty-eight  through  December thirty-first, nineteen hundred ninety,  the  appropriate  weighting  factor  for  each diagnosis-related  group  shall  be  determined  using  nineteen hundred eighty-five costs and statistics for a representative sample of  general hospitals.  For  rate  periods during the period January first, nineteen hundred  ninety-one  through  December  thirty-first,  nineteen  hundred ninety-three,    the    appropriate    weighting    factor    for   each diagnosis-related group  shall  be  determined  using  nineteen  hundred eighty-nine  costs and statistics for a representative sample of general hospitals. For rate periods during the period  January  first,  nineteen hundred  ninety-four  through  December  thirty-first,  nineteen hundred ninety-nine and  on  and  after  January  first,  two  thousand  through December  thirty-first,  two  thousand  seven, the appropriate weighting factor for  each  diagnosis-related  group  shall  be  determined  using nineteen  hundred  ninety-two  costs and statistics for a representative sample of general hospitals. For  rate  periods  on  and  after  January first,  two  thousand  eight,  the appropriate weighting factor for each diagnosis-related group shall be  determined  using  two  thousand  four costs  and  statistics for a representative sample of general hospitals, and, further, the computation of the  group  average  arithmetic  inlier  length-of-stays   for   each  diagnostic  related  group,  as  otherwise determined in accordance with applicable regulations, shall utilize  two thousand  four  data  as  reported to the department, and, be based on a representative  sample of general hospitals, and further, the short-stay and long-stay length-of-stay  trimpoints,  as  otherwise  determined  in accordance  with applicable regulations, shall be computed utilizing two thousand four data  as  reported  to  the  department  and  based  on  a representative  sample  of  general hospitals. Provided however, that if the department does not release updated data and documentation described in subparagraph (iii) of this paragraph, the effective rate period shall be April 1, 2008. Discharges and costs related to the exceptions to case payment provided in accordance with  paragraphs  (e),  (g)  and  (i)  of subdivision  four of this section shall be eliminated from the costs and statistics used in determining the appropriate weighting factors,  while the  cost  factor  related to the exception provided in paragraph (h) of subdivision four of this section shall be eliminated.    The  costs  and statistics  for  the  case  payment modifications calculated pursuant to paragraphs (a), (b), (c) and (d) of subdivision  four  of  this  section shall  be eliminated in accordance with paragraph (c) of subdivision six of this  section.  Costs  related  to  education,  physician,  ambulance services and organ acquisition identified consistent with the provisions of  paragraph (c) of subdivision seven of this section and costs related to malpractice insurance shall also be eliminated. The council may adopt rules and regulations, subject to the approval of the  commissioner,  to prospectively  adjust  weighting  factors  determined in accordance with this paragraph to reflect changes in  medical  technology.    After  the commissioner  issues rate certifications pursuant to subdivision four of section twenty-eight hundred seven  of  this  article  the  commissioner shall  expeditiously  make available for inspection by general hospitals and payors the data, consistent with appropriate  department  procedures for the release and protection of confidential data, and the methodology utilized to determine the appropriate weighting factors.  (ii)  Notwithstanding  any  contrary  provision  of  law, the case mix adjustment to the operating component of per diem rates of payment  paid to  general hospitals or units of general hospitals that are exempt from case based payments, as determined in accordance with  subdivision  four of  this section and as otherwise computed in accordance with applicable regulations, shall, for periods on and after January first, two thousand eight, be computed utilizing the diagnosis-related group  classification system  in  effect  for  the rate year for inpatient case based medicaid rates of payment and the related per day cost weights  calculated  using two  thousand  four  data  as  reported to the department and based on a representative sample of general hospitals.  For  rate  periods  on  and after  the  two  thousand  eleven  rate period, such case mix adjustment shall utilize the same base period data as determined in accordance with paragraph (e) of this subdivision.  (iii) The department shall, by no later than June first, two  thousand seven,  make  available  to  hospital  industry representatives relevant updated data and documentation that  the  department  will  utilize,  in accordance  with  this  paragraph,  in  developing  appropriate  service intensity weights for each diagnosis-related group for the two  thousand eight  rate period. The department will thereafter consult with hospital industry representatives in  developing  regulations  to  implement  the utilization  of such updated service intensity weight data applicable to rate  periods  on  and  after  two  thousand  eight.  If  it  is  deemed appropriate  by the commissioner, in consultation with hospital industry representatives, such regulations may provide for the  phase-in  over  a period  of  time  of the application of such updated data in determining  Medicaid rates on and after two thousand eight, provided, however,  that the  application  of  such updated data shall be fully reflected in such rates by no later than January first, two thousand ten.  (iv)  By  no  later  than  December  first,  two  thousand  seven, the commissioner shall issue a report to the governor  and  the  legislature describing  the  updated data utilization applicable, in accordance with the provisions of this paragraph, to periods on and after  two  thousand eight and setting forth the factors considered in developing it.   * NB Effective until December 31, 2023   * (c) The commissioner shall determine an appropriate weighting factor for  each  diagnosis-related  group  which reflects the relative general hospital resources used by all patients,  other  than  beneficiaries  of title  XVIII of the federal social security act (medicare), with respect to discharges classified within that diagnosis-related group compared to discharges classified within other diagnosis-related  groups.  For  rate periods  during  the period January first, nineteen hundred eighty-eight through December thirty-first, nineteen hundred ninety, the  appropriate weighting  factor  for  each diagnosis-related group shall be determined using  nineteen  hundred  eighty-five  costs  and   statistics   for   a representative  sample of general hospitals. For rate periods during the period January  first,  nineteen  hundred  ninety-one  through  December thirty-first,  nineteen  hundred ninety-three, the appropriate weighting factor for  each  diagnosis-related  group  shall  be  determined  using nineteen  hundred  eighty-nine costs and statistics for a representative sample of general hospitals. For rate periods during the period  January first,  nineteen  hundred  ninety-four  through June thirtieth, nineteen hundred  ninety-six,  the  appropriate   weighting   factor   for   each diagnosis-related  group  shall  be  determined  using  nineteen hundred ninety-two costs and statistics for a representative sample  of  general hospitals.  Discharges  and  costs  related  to  the  exceptions to case payment provided in accordance with  paragraphs  (e),  (g)  and  (i)  of subdivision  four of this section shall be eliminated from the costs and statistics used in determining the appropriate weighting factors,  while the  cost  factor  related to the exception provided in paragraph (h) of subdivision four of this section shall  be  eliminated.  The  costs  and statistics  for  the  case  payment modifications calculated pursuant to paragraphs (a), (b), (c) and (d) of subdivision  four  of  this  section shall  be eliminated in accordance with paragraph (c) of subdivision six of this  section.  Costs  related  to  education,  physician,  ambulance services and organ acquisition identified consistent with the provisions of  paragraph (c) of subdivision seven of this section and costs related to malpractice insurance shall also be eliminated. The council may adopt rules and regulations, subject to the approval of the  commissioner,  to prospectively  adjust  weighting  factors  determined in accordance with this paragraph to reflect  changes  in  medical  technology.  After  the commissioner  issues rate certifications pursuant to subdivision four of section twenty-eight hundred seven  of  this  chapter  the  commissioner shall  expeditiously  make available for inspection by general hospitals and payors the data, consistent with appropriate  department  procedures for the release and protection of confidential data, and the methodology utilized to determine the appropriate weighting factors.   * NB Effective December 31, 2023  (d)  The  commissioner shall consult with technical advisory groups as necessary  in  establishing  diagnosis-related  groups  and  weights  in accordance  with  paragraphs (a), (b) and (c) of this subdivision and in making  adjustments  in  accordance  with  paragraphs  (b)  and  (c)  of subdivision six of this section.  (e) The appropriate weighting factor for each diagnosis-related group, the   group   average   arithmetic   inlier   length-of-stays  for  each diagnosis-related group, and the short-stay and long-stay length-of-stay trimpoints shall, by no later than the two thousand eleven rate  period, be  based  on reported costs and statistics from a representative sample of general hospitals from a base period no  earlier  than  two  thousand seven.  Thereafter,  the  base  period  reported  costs  and  statistics utilized for such purposes shall be  updated  no  less  frequently  than every four years and the new base periods utilized shall be no more than four years prior to the applicable rate period.   3-a.   Dispute   resolution   system.  (a)  * The  commissioner  shall establish, in accordance with  rules  and  regulations  adopted  by  the council  and  approved by the commissioner, a payment dispute resolution system to resolve disputes between payors of inpatient hospital services and general hospitals for patients discharged on or after January first, nineteen hundred ninety-one and prior to January first, nineteen hundred ninety-seven. The commissioner shall designate the use of a uniform  set of   guidelines   for   determining   the   application   of  particular diagnosis-related group categories  to  particular  patients  which  may include  guidelines  published  by  associations,  universities or other organizations. The dispute resolution process shall apply to all  payors of  hospital  services  described  in  paragraphs  (a),  (b)  and (c) of subdivision one of this section, including patients or payors which  pay hospitals' charges or coinsurance, provided, however, such process shall not   include  payments  made  for  persons  eligible  for  payments  as beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare)  as  a  patients'  primary payor or payments made pursuant to title eleven of article five of the social services law,  provided  that this  exception  shall  not  include  payments  for  medical  assistance participants in  health  maintenance  organizations  or  prepaid  health services  plans.  A payor of hospital services included in paragraph (a) of subdivision one of this section  may  serve  as,  or  designate,  the review  agent  for  their subscribers, beneficiaries or enrolled members for an initial review and a reconsideration review but the final step in such dispute resolution process shall be an independent party  unrelated to  the payor which party shall be approved by the commissioner pursuant to this section.   * NB Effective until December 31, 2023   * The commissioner shall  establish,  in  accordance  with  rules  and regulations  adopted  by the council and approved by the commissioner, a payment dispute resolution system to resolve disputes between payors  of inpatient   hospital   services   and  general  hospitals  for  patients discharged on or after January first, nineteen hundred  ninety-one.  The commissioner  shall designate the use of a uniform set of guidelines for determining  the  application  of  particular  diagnosis-related   group categories to particular patients which may include guidelines published by  associations,  universities  or  other  organizations.  The  dispute resolution process shall  apply  to  all  payors  of  hospital  services described  in  paragraphs  (a),  (b)  and (c) of subdivision one of this section, including patients or payors which pay  hospitals'  charges  or coinsurance,  provided, however, such process shall not include payments made for persons eligible for payments as beneficiaries of  title  XVIII of  the  federal  social  security act (medicare) as a patients' primary payor or payments made pursuant to title eleven of article five  of  the social  services  law,  provided  that  this exception shall not include payments for  medical  assistance  participants  in  health  maintenance organizations  or  prepaid  health  services  plans. A payor of hospital services included in paragraph (a) of subdivision one  of  this  section  may  serve  as,  or  designate,  the review agent for their subscribers, beneficiaries  or  enrolled  members  for  an  initial  review   and   a reconsideration  review  but  the  final step in such dispute resolution process shall be an independent party unrelated to the payor which party shall be approved by the commissioner pursuant to this section.   * NB Effective December 31, 2023   In  the  event a third party payor or patient desires to challenge the appropriateness of a bill for hospital services rendered  by  a  general hospital  for  a  particular patient, or in the event a general hospital desires to challenge the appropriateness of a payment by a  third  party payor on behalf of a particular patient, then either the hospital or the payor  may  submit  the  question  to  the  dispute  resolution  process established pursuant to this subdivision.   The disputes  submitted  for resolution  may  include  the  appropriateness  of  the application of a particular diagnosis-related group category, as described in subdivision three  of  this  section,  to  a  particular  patient;  the  appropriate classification  and  payment of an inpatient stay as a modification of a case payment pursuant to paragraph (a), (b), (c), or (d) of  subdivision four  of this section, including whether payment for services should be, based on medical necessity or other reasons, made as a case  payment  or payment  as  a  modification  of  a case payment; whether payment should appropriately  be  made  pursuant  to   an   alternative   reimbursement methodology  authorized  in  accordance  with  paragraph  (e)  or (h) of subdivision four of this section and  the  payment  for  such  services; whether  payment  for  services rendered by a general hospital should be appropriately, based on medical necessity  or  other  reasons,  made  as payment  for  inpatient  care  or  payment  for  outpatient care and the payment for such services;  or  whether  the  hospital  stay  should  be classified  as  a  readmission as defined in accordance with regulations adopted pursuant to paragraph (l) of subdivision eleven of this  section and the payment for such stay.   The dispute resolution system established shall provide for an initial review  and  a reconsideration review. The council shall adopt necessary rules and regulations, subject to  the  approval  of  the  commissioner, including  but  not  limited  to  those for determining the parties to a dispute resolution review and any reconsideration review; the procedures and  time  limits  to  initiate  a  dispute  resolution  review  or  any reconsideration  review;  the procedures for notification of all parties involved in the dispute upon initiation of a dispute  resolution  review or  any  reconsideration review; time limits for resolving disputes; the establishment  of  dispute  resolution  and  reconsideration  fees;  and required  documents  to  be  submitted  including  the  hospital bill in dispute, a copy of the patient medical record, or so much thereof as may be required, and a statement of  issues  including  the  basis  for  the dispute.  During  a  dispute  resolution  review  or any reconsideration review, a party may present documentation or evidence in support of  its position  regarding the appropriate diagnosis-related group to which the patient discharge should be assigned or the proper payment for the case. The  commissioner  shall  approve   a   statewide   utilization   review organization  or regional utilization review organization to conduct and determine such dispute resolution reviews including any  reconsideration reviews  in  accordance  with  paragraph (b) of this subdivision.  Every general hospital bill issued  for  a  patient  discharged  on  or  after January  first, nineteen hundred ninety-one other than for discharges of patients eligible for medical assistance pursuant  to  title  eleven  of article  five  of the social services law subject to case based payments determined pursuant to this section  based  on  diagnosis-related  group assigned  or  maximum hospital charges for a case determined pursuant to  this section based on diagnosis-related group assigned shall include  or be  accompanied  by  a  notice of the payment dispute resolution system; provided, however, that a general hospital issuing bills to a payor  for twenty-five or more patients per year may send such notice to such payor on  an  annual  basis.  The  form  and  content  of such notice shall be determined in accordance with  rules  and  regulations  adopted  by  the council and approved by the commissioner.  (b)  The  commissioner  shall  approve  a statewide utilization review organization or regional utilization review organizations to conduct and determine dispute resolution reviews, including reconsideration reviews, pursuant to this subdivision. To be approved  as  a  utilization  review organization  in accordance with this subdivision such organization must meet the following criteria: the organization shall employ or  otherwise secure  the services of adequate personnel, including medical personnel, qualified to review such disputes, the  organization  shall  demonstrate the  ability  to  render  decisions in a timely manner, the organization shall agree to provide ready access by the  commissioner  to  all  data, records  and information it collects and maintains concerning its review activities under this  subdivision,  the  organization  shall  agree  to provide  to  the  commissioner such data, information and reports as the commissioner  determines  necessary  to  evaluate  the  review   process provided  pursuant  to  this subdivision, the organization shall provide assurances that review personnel shall not have a conflict  of  interest in  conducting  a  review  based  on  payor,  hospital  or  professional affiliation, and the  organization  meets  such  other  performance  and efficiency  criteria  regarding  the conduct of reviews pursuant to this subdivision  established  by  the  commissioner.  The  commissioner  may withdraw  approval  of  a  utilization  review  organization  where such organization fails to continue to  meet  approval  criteria  established pursuant  to  this paragraph. A utilization review organization approved pursuant to this paragraph shall be authorized  to  receive  and  review patient  medical  records  and  shall  develop and implement appropriate procedures to maintain confidentiality of such patient medical records.  (c) Upon resolution of a  payment  dispute  in  accordance  with  this paragraph,  the parties involved in the dispute shall be notified of the reason for the decision and  the  hospital  bill  in  dispute  shall  be adjusted to reflect such resolution.  (d)  The  party  initiating a payment dispute resolution review or any reconsideration  review  must   submit   to   the   utilization   review organization  a  dispute resolution fee established to recover the costs related to the conduct of the initial dispute resolution  reviews  or  a reconsideration  review  fee established to recover the costs related to the conduct of such reconsideration reviews, except that for  payors  in paragraph  (a)  of  subdivision  one  of  this section which serve as or designate the review agent  for  their  subscribers,  beneficiaries,  or enrolled  members  a fee shall be charged only for the final step in the dispute resolution process. Upon resolution  of  a  payment  dispute  in accordance  with  this subdivision in favor of the payor, the amount due to the hospital by a payor based upon the hospital bill shall be reduced by the amount of any fee paid pursuant to this paragraph by such  payor. Upon resolution of a payment dispute in accordance with this subdivision in  favor  of the general hospital, the amount due to the hospital based upon the hospital bill shall be increased by the amount of any fee  paid pursuant to this paragraph by such general hospital.  (e) Nothing herein shall relieve the responsibilities of the payors as set  forth  in  paragraphs  (a),  (b) and (c) of subdivision one of this section.  (f)(i) Whenever the amount of payment made by a  payor  to  a  general hospital  is  less  than  the  amount  of  payment  due  determined by a utilization review organization in  accordance  with  this  subdivision, general hospitals in accordance with paragraph (d) of subdivision eleven of this section may include financing or working capital charges on such balance owed to the general hospital by a payor.  (ii)  Whenever  the  amount  of  payment  made by a payor to a general hospital is in excess of the amount  of  payment  due  determined  by  a utilization  review  organization  in  accordance with this subdivision, interest shall be due on such excess owed by the general hospital  to  a payor of two percent for the first thirty days and one percent per month thereafter  from  the  date  of  payment of such excess amount. Interest shall not be applied to  excess  amounts  owed  to  third  party  payors participating in an advance payment system.  (g)  For  payment  amounts  eligible  for  payment  dispute resolution pursuant to this subdivision,  a  general  hospital  shall  not  bill  a patient   or  pursue  collection  efforts  against  a  patient  for  the difference between a hospital bill and the payment made on such bill  by a  payor  within the payor categories specified in paragraph (a), (b) or (c) of subdivision one of this section, except for uncovered services by a payor, deductibles and coinsurance based on maximum  hospital  charges calculated  based  on  the undisputed amount of the hospital bill, until final decision of the utilization review organization. Nothing  in  this subdivision  shall  be  construed  to  prohibit  a general hospital from issuing an informational bill to a  patient  regarding  such  difference between  the  hospital  bill and the payment made on such bill to advise the patient of the amount in dispute.  (h) The formal written decision of a utilization  review  organization approved by the commissioner to conduct and determine dispute resolution reviews  in  accordance  with  paragraph  (b) of this subdivision upon a reconsideration review, or if there is no reconsideration review upon an initial review,  or  for  a  payor  of  hospital  services  included  in paragraph  (a)  of  subdivision  one  of this section which serves as or designates the review agent  for  their  subscribers,  beneficiaries  or enrolled  members  upon the final step in the dispute resolution process as to the questions of  the  appropriateness  of  a  bill  for  hospital services  or  the  calculation  of  the proper payment for such hospital services shall be admissible in evidence at any  subsequent  trial  upon the  request  of  any  party  to  the  action. The decision shall not be binding upon the jury or, in a case tried without a jury, upon the trial court, but shall be considered prima facie  evidence  to  establish  the facts resolved by the utilization review organization.   4.  Modifications  and  exceptions  to  case payment rates. Case based rates of payment shall be modified and per diem or other unit of service payments shall  be  provided,  or  exceptions  shall  be  made  to  case payments,  in  accordance  with  rules  and  regulations  adopted by the council  and  approved   by   the   commissioner,   in   the   following circumstances:  (a)  where  a  case  that is eligible for payment under the case based payment system is transferred between general hospitals,  the  receiving hospital  shall  be  reimbursed  its  total  case payment amount for the diagnosis-related group (including any payments made in accordance  with this   subdivision),   and   the  transferring  hospital  shall  receive reimbursement on a basis consistent with the methodology  developed  for the   elimination   of   transfer   patient  costs  in  accordance  with subparagraph (i) of paragraph (c) of subdivision  six  of  this  section plus  additions  contained  in  subparagraph  (ii)  of  paragraph (a) of subdivision one of this section on a per diem basis. The  payment  to  a  transferring  general  hospital shall not exceed the case payment amount for  the  diagnosis-related  group  computed  in  accordance  with  this section;  (b)  where  the  cost per case for a patient that does not qualify for payment pursuant to paragraph (a) or  (d)  of  this  subdivision  is  in excess  of  the  basic case payment rate for the diagnosis-related group multiplied by two and the overall  hospital-specific  average  cost  per case  multiplied by six, the payment to the general hospital in addition to the basic case payment rate will be  one  hundred  percent,  or  such percentage as computed in accordance with subparagraph (ii) of paragraph (c)  of  subdivision  six  of this section, multiplied by the difference between the general hospital's cost for the case and the greater of  the basic  case  payment  rate for the diagnosis-related group multiplied by two or the overall hospital-specific cost per case multiplied by six. In determining whether a case qualifies for payment under  this  paragraph, prospective  rate  adjustments  made in accordance with paragraph (c) of subdivision eleven of this section to reflect the retroactive impact  of an  adjustment on prior rates, shall be excluded. Where a case qualifies for payment pursuant to both this paragraph and paragraph  (c)  of  this subdivision then payment shall be made in accordance with this paragraph if  such  payment  exceeds  that  which would be made in accordance with paragraph (c) of this subdivision. The general hospital's costs per case shall be computed by adjusting the general hospital's actual charges for the case by the general hospital's inpatient cost to charge ratio;  (c) where a patient is identified as a long stay patient,  payment  to the general hospital in addition to the basic case payment rate shall be on a basis consistent with the methodology developed for the elimination of  long  stay  patient  costs  in accordance with subparagraph (iii) of paragraph (c) of subdivision six of this section. Where a case qualifies for payment pursuant to both this paragraph and paragraph  (b)  of  this subdivision  then payment shall be made in accordance with paragraph (b) of this subdivision if such payment exceeds that which would be made  in accordance  with  this  paragraph.  A long stay patient is defined as an inpatient whose hospital stay exceeds the long  stay  outlier  threshold for the diagnosis-related group;  (d)  where a patient is identified as a short stay patient, payment to the general hospital shall be on a basis consistent with the methodology developed for the elimination of short stay patient costs in  accordance with  subparagraph  (iv)  of  paragraph  (c)  of subdivision six of this section plus additions contained in subparagraph (ii) of  paragraph  (a) of  subdivision  one  of  this section on a per diem basis. A short stay patient is defined as an inpatient discharged from the hospital  on  the same day of admission, or the day after admission except for those stays where  the statewide mean length of stay for the diagnosis-related group is less than three days, or whose hospital  stay  is  not  greater  than twenty   percent   of   the  statewide  mean  length  of  stay  for  the diagnosis-related group with which the patient is identified,  excluding normal newborn cases and normal deliveries;  (e)  in  cases  where a general hospital or distinct unit of a general hospital is not or would not  have  been  reimbursed  on  a  case  based payment  per  diagnosis-related group for inpatient services provided on or before December thirty-first, two thousand one, to  beneficiaries  of title XVIII of the federal social security act (medicare), reimbursement shall  be  on  a  per diem basis computed for excluded general hospitals based on the hospital's reimbursable inpatient operating cost  base,  or for  excluded  distinct units of general hospitals based on the distinct unit's  reimbursable  inpatient  operating  cost  base,  determined   in accordance  with  paragraph  (d)  of  subdivision  one  of this section,  projected to the applicable rate period by the trend  factor  determined in  accordance  with  subdivision  ten of this section, and increased in accordance with subparagraphs (i), (iii) and (iv) of  paragraph  (e)  of subdivision  one of this section to reflect special additional inpatient operating costs, and adjusted to exclude a factor for operating costs of patients who required an alternate level of  care  developed  consistent with  the provisions of paragraph (h) of this subdivision, and increased for excluded general hospitals to  reflect  the  product  of  the  group category  percentage amount applicable for purposes of determining group category average inpatient reimbursable  operating  cost  per  discharge (price) in the rate period pursuant to paragraph (b) of subdivision five of this section for general hospitals reimbursed on a case based payment per  diagnosis-related group applied to such excluded general hospital's additional cost increases determined  in  accordance  with  subparagraph (ii)  of  paragraph (e) of subdivision one of this section, and adjusted on a payor category basis to reflect allocation of malpractice insurance costs  in  accordance  with  the  methodology  developed   pursuant   to subparagraph  (ii)  of  paragraph  (h)  of  subdivision  eleven  of this section, for those patients included in the payor categories pursuant to the provisions of paragraph (a)  or  (b)  of  subdivision  one  of  this section;  provided,  however,  for  those patients included in the payor categories pursuant to the provisions of paragraph  (b)  of  subdivision one  of  this  section  payment  shall be at the per diem payment to the hospital or distinct unit of  the  hospital  for  services  provided  to subscribers  of  corporations organized and operating in accordance with article  forty-three  of  the  insurance  law,  adjusted  for  uncovered services,  and  increased by thirteen percent or by five percent, as the case may be; provided further, however, for those general hospitals that are not reimbursed on a case-based payment per  diagnosis-related  group for  inpatient  services provided to beneficiaries of title XVIII of the federal social security act (medicare) as a result of their  designation by  the secretary of health and human services as a comprehensive cancer hospital or as a  result  of  their  status  as  an  acute  care  exempt children's hospital, the base year for determining payments for services in  such  facilities  shall  be nineteen hundred eighty-seven, provided, however, such hospitals shall be allowed adjustments in rates of payment to reflect costs incurred subsequent to  nineteen  hundred  eighty-seven but  not  reflected  in  such base. Funds received by a general hospital based on the payment differential in accordance with  paragraph  (b)  of subdivision one of this section applied pursuant to this paragraph shall be  hospital  funds  for  patient  care purposes. For those patients not covered under the provisions of paragraph (a) or (b) of subdivision  one of  this  section,  or  who  are  not  covered  under  the provisions of paragraph (a) of subdivision two of this section, payment  shall  be  on the  basis  of  the  hospital's  charge schedule, limited to one hundred twenty percent of the total per diem payment that would have  been  made if  the  patient  were  included in the payor categories pursuant to the provisions of paragraph (b) of subdivision one of this section. Rates of payment for excluded general hospitals and excluded  distinct  units  of general  hospitals  for  a  rate period shall be increased on a per diem basis by additions and allowances specified in  subparagraphs  (ii)  and (iii)  of  paragraph (a) of subdivision one of this section. In adopting regulations for purposes of determining rates of payment for psychiatric services pursuant to this paragraph, the council  and  the  commissioner shall  consider  the advice of the commissioner of mental health and may include case mix and other adjustments for such rates  of  payment.  The commissioner  of  mental  health  shall  study and report on alternative procedures for  the  development  of  rates  of  payment  for  inpatient  psychiatric  care.  Such  report shall be submitted to the governor, the legislature and the commissioner of health by  January  first,  nineteen hundred  ninety-three.  Recommendations  for alternative financing shall take  into consideration methods to improve access to inpatient care for seriously mentally ill persons.  (e-1) Notwithstanding any inconsistent provision of paragraph  (e)  of this  subdivision  or any other contrary provision of law and subject to the availability of federal financial participation, per diem  rates  of payment  by  governmental  agencies for a general hospital or a distinct unit of a general hospital for inpatient psychiatric services that would otherwise be  subject  to  the  provisions  of  paragraph  (e)  of  this subdivision  shall,  with  regard  to  days  of  service associated with admissions occurring on and after April first, two thousand ten,  be  in accordance with the following:  (i)  For  rate  periods on or after April first, two thousand ten, the commissioner, in consultation with the commissioner  of  the  office  of mental   health,   shall  promulgate  regulations,  and  may  promulgate emergency regulations, establishing methodologies  for  determining  the operating cost components of rates of payments for services described in this  paragraph.  The  commissioner  may  make  such  adjustments to the methodology for computing such rates  as  is  necessary  to  achieve  no aggregate,  net  growth in overall Medicaid expenditures related to such rates, as compared to such aggregate expenditures from the  prior  year. In  determining  the  updated  base year to be utilized pursuant to this subparagraph, the commissioner shall take into  account  the  base  year determined  in  accordance with paragraph (c) of subdivision thirty-five of this section.   Furthermore,  the  commissioner  shall   establish   such   rates   in consultation  with  industry  representatives  to achieve an appropriate base year update to the operating cost components of  rates  of  payment for  services  described  in  this paragraph and that takes into account facility cost, mix of services, and patient specific conditions.  (ii) Rates of payment established pursuant to subparagraph (i) of this paragraph  shall  reflect  an  aggregate  net  statewide   increase   in reimbursement  for such services of up to twenty-five million dollars on an annual basis.  (iii) Capital  cost  reimbursement  for  general  hospitals  otherwise subject  to the provisions of this paragraph shall remain subject to the provisions of subdivision eight of this section.  (e-2) Notwithstanding any inconsistent provision of paragraph  (e)  of this  subdivision  or any other contrary provision of law and subject to the availability of federal financial participation, per diem  rates  of payment  by  governmental  agencies for inpatient services provided by a general hospital or a distinct unit of a general hospital for  services, as described below, that would otherwise be subject to the provisions of paragraph (e) of this subdivision, shall, with regard to days of service occurring  on  and after December first, two thousand nine, be in accord with the following:  (i) For physical medical  rehabilitation  services  and  for  chemical dependency rehabilitation services, the operating cost component of such rates  shall  reflect  the  use of two thousand five operating costs for each respective category of services as reported by each facility to the department prior to July first, two thousand nine and  as  adjusted  for inflation  pursuant to paragraph (c) of subdivision ten of this section, as otherwise modified by any applicable statute, provided, however, that such two thousand five  reported  operating  costs,  but  not  including reported   direct   medical  education  cost,  shall,  for  rate-setting purposes, be held to a ceiling of one hundred ten percent of the average  of such reported costs in the region in which the facility  is  located, as  determined  pursuant to clause (E) of subparagraph (iv) of paragraph (1) of this  subdivision;  and  provided,  further,  that  for  physical medical  rehabilitation services, the commissioner is authorized to make adjustments to such rates for  the  purposes  of  reimbursing  pediatric ventilator services.  (ii)  For  services provided by rural hospitals designated as critical access hospitals in accordance with title XVIII of  the  federal  social security  act,  the operating cost component of such rates shall reflect the use of two  thousand  five  operating  costs  as  reported  by  each facility to the department prior to July first, two thousand nine and as adjusted  for  inflation pursuant to paragraph (c) of subdivision ten of this  section,  as  otherwise  modified  by  any  applicable   statutes, provided,  however, that such two thousand five reported operating costs shall, for rate-setting purposes, be held to a ceiling  of  one  hundred ten  percent  of  the  average  of  such  reported  costs  for  all such designated hospitals statewide.  (iii) For inpatient services provided by  specialty  long  term  acute care  hospitals  and for inpatient services provided by cancer hospitals as so designated as of December thirty-first, two  thousand  eight,  the operating  cost  component  of  such  rates shall reflect the use of two thousand five operating costs for each respective category  of  facility as  reported by each facility to the department prior to July first, two thousand nine and as adjusted for inflation pursuant to paragraph (c) of subdivision ten of this section, as otherwise modified by any applicable statutes.  (iv) For facilities designated by the federal department of health and human services as exempt acute care children's hospitals as of  December thirty-first,  two  thousand  eight,  for which a discrete institutional cost report was filed for the two  thousand  seven  calendar  year,  and which  has  reported  Medicaid  discharges greater than fifty percent of total discharges in such cost report, shall be determined in  accordance with the following:  (A)  The  operating cost component of such rates shall reflect the use of two thousand seven operating costs as reported by  each  facility  to the  department  prior  to July first, two thousand nine and as adjusted for the inflation pursuant to paragraph (c) of subdivision ten  of  this section,  as  otherwise  modified  by  any  applicable  statutes, and as further  adjusted  as  the  commissioner  deems  appropriate,  including transition  adjustments.  Such  rates  shall be determined on a per case basis or per diem basis, as set forth in regulations promulgated by  the commissioner.  (B) The operating component of outpatient specialty rates of hospitals subject to this subparagraph shall reflect the use of two thousand seven operating  costs  as reported to the department prior to December first, two  thousand  eight,  and  shall  include  such  adjustments   as   the commissioner deems appropriate.  (C)  The  base  period  reported  operating  costs  used  to establish inpatient and outpatient rates determined pursuant to this  subparagraph shall  be  updated no less frequently than every two years and each such hospital shall submit such  additional  data  as  the  commissioner  may require to assist in the development of ambulatory patient groups (APGs) rates for such hospitals' outpatient specialty services.  (D)  Notwithstanding  any  other provisions of law to the contrary and subject to the availability of federal financial participation, for  all rate  periods  on  and  after  April  first,  two thousand fourteen, the operating component of outpatient specialty rates of  hospitals  subject to this subparagraph shall be determined by the commissioner pursuant to  regulations,  including  emergency regulations, and in consultation with such specialty outpatient facilities, provided  however,  that  for  the period  beginning October first, two thousand thirteen through September thirtieth, two thousand fourteen, services provided to patients enrolled in  medicaid  managed  care  shall  be paid by the medicaid managed care plans at no less than the otherwise applicable medicaid  fee-for-service rates,  as  computed  in accordance with clause (B) of this subparagraph for the period beginning October first, two  thousand  thirteen  through March  thirty-first, two thousand fourteen and as computed in accordance with this clause for the period  beginning  April  first,  two  thousand fourteen through September thirtieth, two thousand fourteen.  (E) For facilities subject to the provisions of this subparagraph, the department  shall examine the feasibility of reimbursing such facilities for services provided to children eligible for medical assistance  on  a non-fee-for-service    basis.    For    purposes    of    this   clause, "non-fee-for-service" shall be defined as an alternative payment  method to   bundle  certain  services  rendered  by  such  facility,  including inpatient, outpatient, specialty outpatient and physician  services,  in amounts determined by the commissioner. The department shall examine:  (a)    what    services    could   be   provided   pursuant   to   the non-fee-for-service basis;  (b) how to ensure, for children enrolled  in  Medicaid  managed  care, that  their  health  plans can continue to assist in the coordination of their care, particularly upon discharge from  inpatient,  outpatient  or specialty outpatient services; and  (c)  whether  incentives  should  be  incorporated for meeting quality benchmarks or achieving efficiencies in the delivery and coordination of care or whether other  means  should  be  considered  to  achieve  these objectives.   The   department   shall   provide   a  report  of  its  findings  and recommendations to the governor and  legislature  no  later  than  March first, two thousand fifteen.  (v)  Rates  established  pursuant to this paragraph shall be deemed as excluding reimbursement for physician services  for  inpatient  services and  claims  for  Medicaid  fee payments for such physician services for such inpatient care  may  be  submitted  separately  from  the  rate  in accordance with otherwise applicable law.  (vi)  Capital  cost  reimbursement  for  general  hospitals  otherwise subject to the provisions of this paragraph shall remain subject to  the provisions of subdivision eight of this section.  (vii) The commissioner may promulgate regulations, including emergency regulations,   implementing  the  provisions  of  this  paragraph,  and, further, such regulations may provide for an update  of  the  base  year costs and statistics used to compute such rates, provided, however, that such base year update shall take effect no earlier than April first, two thousand  fifteen,  and provided further, however, that the commissioner may make such adjustments to such utilization and to the methodology for computing such rates as is necessary to achieve no aggregate, net growth in overall Medicaid expenditures related to such rates, as  compared  to such  aggregate  expenditures  from  the  prior year. In determining the updated base year to be utilized  pursuant  to  this  subparagraph,  the commissioner  shall  take  into  account  the  base  year  determined in accordance  with  paragraph  (c)  of  subdivision  thirty-five  of  this section.  (viii)  The  operating  cost component of rates of payment pursuant to this paragraph for a general hospital or  distinct  unit  of  a  general hospital without adequate cost experience shall be based on the lower of  the  facility's  or  unit's  inpatient budgeted operating costs per day, adjusted to actual, or the applicable regional ceiling, if any.  (ix)  The operating cost component of inpatient medicaid rates subject to subparagraphs (i), (ii) and  (iii)  of  this  paragraph  shall,  with regard  to  alternative  level  of care (ALC) days of care be subject to computation pursuant to paragraph (h) of this subdivision.   * (f) where a general hospital having two hundred  or  less  certified acute  care beds, based on the total number of inpatient acute care beds for which such general hospital is certified pursuant to  the  operating certificate  issued for such general hospital in accordance with section twenty-eight hundred five of this article in effect on  June  thirtieth, nineteen  hundred ninety, is classified as a rural hospital for purposes of determining payment for inpatient services provided to  beneficiaries of  title  XVIII  of the federal social security act (medicare) or under state regulations, such general hospital may  at  its  option  have  its reimbursable  inpatient  operating cost component of case based rates of payment per diagnosis-related group based one  hundred  percent  on  the general  hospital's  hospital-specific  average  reimbursable  inpatient operating cost per discharge determined in accordance  with  subdivision six  of this section; provided however, commencing April first, nineteen hundred ninety-six the reimbursable inpatient operating  cost  component of  case based rates of payment per diagnosis-related group for patients eligible for payments made  by  state  governmental  agencies  shall  be reduced   by   five  percent  to  encourage  improved  productivity  and efficiency. Such election shall not alter the calculation of  the  group price component calculated pursuant to subparagraph (i) of paragraph (a) of subdivision seven of this section;   * NB There are 2 par. (f)'s   * (f)  where  a  general hospital having two hundred or less certified acute care beds, based on the total number of inpatient acute care  beds for  which  such general hospital is certified pursuant to the operating certificate issued for such general hospital in accordance with  section twenty-eight  hundred  five of this article in effect on June thirtieth, nineteen hundred ninety, is classified as a rural hospital for  purposes of  determining payment for inpatient services provided to beneficiaries of title XVIII of the federal social security act  (medicare)  or  under state  regulations,  such  general  hospital  may at its option have its reimbursable inpatient operating cost component of case based  rates  of payment  per  diagnosis-related  group  based one hundred percent on the general  hospital's  hospital-specific  average  reimbursable  inpatient operating  cost  per discharge determined in accordance with subdivision six of this section; provided however,  (i) commencing April first, nineteen hundred ninety-six  through  July thirty-first,  nineteen  hundred  ninety-six, the reimbursable inpatient operating  cost  component  of  case  based   rates   of   payment   per diagnosis-related group, excluding any operating cost components related to  direct  and  indirect  expenses  of  graduate medical education, for patients eligible for payments made by state governmental agencies shall be reduced by five percent; and  (ii) commencing August  first,  nineteen  hundred  ninety-six  through March  thirty-first,  nineteen  hundred  ninety-seven,  the reimbursable inpatient operating cost component of case based rates  of  payment  per diagnosis-related group, excluding any operating cost components related to  direct  and  indirect  expenses  of  graduate medical education, for patients eligible for payments made by state governmental agencies shall be reduced by two and five-tenths percent; and  (iii) commencing April first, nineteen  hundred  ninety-seven  through March  thirty-first,  nineteen  hundred  ninety-nine and commencing July  first, nineteen hundred  ninety-nine  through  March  thirty-first,  two thousand  and  April first, two thousand through March thirty-first, two thousand five and for periods commencing April first, two thousand  five through  March thirty-first, two thousand six and for periods commencing on and after April first, two thousand six through  March  thirty-first, two thousand seven, and for periods commencing on and after April first, two  thousand  seven  through March thirty-first, two thousand nine, and for periods commencing on and  after  April  first,  two  thousand  nine through  March  thirty-first,  two  thousand  eleven,  the  reimbursable inpatient operating cost component of case based rates  of  payment  per diagnosis-related group, excluding any operating cost components related to  direct  and  indirect  expenses  of  graduate medical education, for patients eligible for payments made by state governmental agencies shall be reduced by three and thirty-three  hundredths  percent  to  encourage improved  productivity and efficiency. Such election shall not alter the calculation  of  the  group  price  component  calculated  pursuant   to subparagraph (i) of paragraph (a) of subdivision seven of this section;   * NB Effective until December 31, 2023   * (f)  where  a  general hospital having two hundred or less certified acute care beds, based on the total number of inpatient acute care  beds for  which  such general hospital is certified pursuant to the operating certificate issued for such general hospital in accordance with  section twenty-eight  hundred  five of this article in effect on June thirtieth, nineteen hundred ninety, is classified as a rural hospital for  purposes of  determining payment for inpatient services provided to beneficiaries of title XVIII of the federal social security act  (medicare)  or  under state  regulations,  such  general  hospital  may at its option have its reimbursable inpatient operating cost component of case based  rates  of payment  per  diagnosis-related  group  based one hundred percent on the general  hospital's  hospital-specific  average  reimbursable  inpatient operating  cost  per discharge determined in accordance with subdivision six of this section; provided however,  (i) commencing April first, nineteen hundred ninety-six  through  July thirty-first,  nineteen  hundred  ninety-six, the reimbursable inpatient operating  cost  component  of  case  based   rates   of   payment   per diagnosis-related group, excluding any operating cost components related to  direct  and  indirect  expenses  of  graduate medical education, for patients eligible for payments made by state governmental agencies shall be reduced by five percent; and  (ii) commencing August  first,  nineteen  hundred  ninety-six  through March  thirty-first,  nineteen  hundred  ninety-seven,  the reimbursable inpatient operating cost component of case based rates  of  payment  per diagnosis-related group, excluding any operating cost components related to  direct  and  indirect  expenses  of  graduate medical education, for patients eligible for payments made by state governmental agencies shall be reduced by two and five-tenths percent; and  (iii) commencing April first, nineteen  hundred  ninety-seven  through March  thirty-first,  nineteen  hundred  ninety-nine and commencing July first, nineteen hundred  ninety-nine  through  March  thirty-first,  two thousand,  the  reimbursable  inpatient operating cost component of case based rates  of  payment  per  diagnosis-related  group,  excluding  any operating  cost  components  related  to direct and indirect expenses of graduate medical education, for patients eligible for payments  made  by state  governmental  agencies shall be reduced by three and thirty-three hundredths percent to encourage improved  productivity  and  efficiency. Such  election  shall  not  alter  the  calculation  of  the group price component calculated pursuant to subparagraph (i) of  paragraph  (a)  of subdivision seven of this section;    * NB Effective and expires December 31, 2023   * (f)  where  a  general hospital having two hundred or less certified acute care beds, based on the total number of inpatient acute care  beds for  which  such general hospital is certified pursuant to the operating certificate issued for such general hospital in accordance with  section twenty-eight  hundred  five of this article in effect on June thirtieth, nineteen hundred ninety, is classified as a rural hospital for  purposes of  determining payment for inpatient services provided to beneficiaries of title XVIII of the federal social security act  (medicare)  or  under state  regulations,  such  general  hospital  may at its option have its reimbursable inpatient operating cost component of case based  rates  of payment  per  diagnosis-related  group  based one hundred percent on the general  hospital's  hospital-specific  average  reimbursable  inpatient operating  cost  per discharge determined in accordance with subdivision six of this section. Such election shall not alter  the  calculation  of the  group  price  component  calculated pursuant to subparagraph (i) of paragraph (a) of subdivision seven of this section;   * NB Effective December 31, 2023   * NB There are 2 par (f)'s  (g) in cases where general hospitals  or  distinct  units  of  general hospitals,  other than those specified in paragraphs (e) and (f) of this subdivision, may be excluded from case  based  payments  or  receive  an adjustment to case based payment rates. An exclusion or adjustment shall be  provided  only  where  the  council,  subject to the approval of the commissioner, determines that the case based rates of payment determined in accordance with this section would not reflect medically  appropriate patterns  of  health  resource  use  for  such general hospital services efficiently and economically provided. If an exclusion is provided, then the  reimbursement  provisions  contained  in  paragraph  (e)  of   this subdivision  shall  apply. The commissioner shall provide to the council an analysis of the effect  of  case  based  payments  on  rural  general hospitals  and  the  council,  subject  to  the  above  criteria and the approval of the commissioner, may exclude for any  of  the  annual  rate periods   beginning   on   or  after  January  first,  nineteen  hundred eighty-eight any of these general hospitals from case based payments  or provide  an  adjustment  to  the case based payments in addition to that authorized in accordance with paragraph (f) of this subdivision;  (h) where alternate level of care (ALC) days are provided, a factor as determined in subparagraph (i) of this paragraph for the costs of  these patients  in  a  general  hospital shall not be included in computations relating to the determination of general hospital case  based  rates  of payment  pursuant to this section. Alternate level of care days shall be days of care provided by a general hospital to a patient for whom it has been determined that  inpatient  hospital  services  are  not  medically necessary,  but  that post-hospital extended care services are medically necessary and are being provided by the general hospital. Separate rates of payment shall be established for such patients based on the level  of care  required  and  shall  reflect:  (i)  operating  costs based on the nineteen hundred eighty-seven regional average operating cost  component of   rates  of  payment  for  hospital  based  residential  health  care facilities determined in accordance with  section  twenty-eight  hundred eight of this article and trended to the rate period, and (ii) additions contained  in  subparagraph (iii) of paragraph (a) of subdivision one of this section. In the  event  that  federal  financial  participation  in payments  made  for  beneficiaries eligible for medical assistance under title XIX of the federal  social  security  act  based  upon  the  rates calculated  in  accordance  with  this  paragraph is not approved by the  federal  government,  the  council  subject  to  the  approval  of   the commissioner shall adopt regulations for such payments;  (i)  if  diagnosis-related  groups  are not adjusted or established in accordance with paragraph (a) of subdivision three of this  section  for services  to  acquired  immune deficiency syndrome (AIDS) patients, then general hospitals shall receive separate  payments  for  these  patients based  on  regulations  adopted  by  the  council  and  approved  by the commissioner;  (j) where general hospitals or distinct units of general hospitals are excluded from or receive  an  adjustment  to  case  based  payments  per diagnosis-related  group in accordance with paragraph (e), (f) or (g) of this subdivision, reimbursement  shall  continue  to  be  calculated  in accordance  with  such  paragraph until the beginning of the rate period immediately following the date when the general hospital or the distinct unit of the general hospital is no longer excluded  from  or  no  longer receives  an  adjustment  to  case  based payments per diagnosis-related group for inpatient services provided to beneficiaries of title XVIII of the  federal  social  security  act  (medicare),  or  until  appropriate diagnosis-related groups have been developed for the specialized service provided  by  the  general  hospital  or  distinct  unit  of the general hospital, pursuant  to  paragraph  (a)  of  subdivision  three  of  this section; and   * (k)  for  facilities  designated by the federal department of health and human services as an exempt acute care children's hospital,  payment effective January first, nineteen hundred ninety-four will be based upon a  hospital specific case payment amount inclusive of high cost and high length of stay outlier costs. The  nineteen  hundred  eighty-seven  base year  cost,  trended,  volume  adjusted  and  case  mix  adjusted  where applicable to nineteen hundred ninety-two, trended will be  utilized  to determine  the rate of payment effective January first, nineteen hundred ninety-four. Commencing April first, nineteen  hundred  ninety-six,  the operating  cost  component of rates of payment for patients eligible for payments made by a state governmental agency shall be  reduced  by  five percent  to encourage improved productivity and efficiency. The facility will be eligible to receive the financial incentives for  the  physician specialty   weighting   incentive   towards  primary  care  pursuant  to subparagraph (ii) of paragraph (a) of subdivision  twenty-five  of  this section.   * NB There are 2 par (k)'s   * (k)  for  facilities  designated by the federal department of health and human services as an exempt acute care children's hospital,  payment effective January first, nineteen hundred ninety-four will be based upon a  hospital specific case payment amount inclusive of high cost and high length of stay outlier costs. The  nineteen  hundred  eighty-seven  base year  cost,  trended,  volume  adjusted  and  case  mix  adjusted  where applicable to nineteen hundred ninety-two, trended will be  utilized  to determine  the rate of payment effective January first, nineteen hundred ninety-four.  (i) Commencing April first, nineteen hundred ninety-six  through  July thirty-first,  nineteen hundred ninety-six, the operating cost component of rates of payment, excluding any operating cost components related  to direct and indirect expenses of graduate medical education, for patients eligible  for  payments  made  by  a  state governmental agency shall be reduced by five percent; and  (ii) commencing August  first,  nineteen  hundred  ninety-six  through March  thirty-first,  nineteen  hundred  ninety-seven the operating cost component of rates of payment, excluding any operating  cost  components related  to  direct and indirect expenses of graduate medical education,  for patients eligible for payments made by a state  governmental  agency shall be reduced by two and five-tenths percent; and  (iii)  commencing  April  first, nineteen hundred ninety-seven through March thirty-first, nineteen hundred  ninety-nine  and  commencing  July first,  nineteen  hundred  ninety-nine  through  March thirty-first, two thousand and April first, two thousand through March  thirty-first,  two thousand  five  and  commencing  April  first, two thousand five through March thirty-first, two thousand six, and for periods commencing on  and after  April  first,  two  thousand  six through March thirty-first, two thousand seven, and for periods commencing on and after April first, two thousand seven through March thirty-first, two thousand  nine,  and  for periods  commencing  on and after April first, two thousand nine through March thirty-first, two thousand eleven, the operating cost component of rates of payment, excluding any operating  cost  components  related  to direct and indirect expenses of graduate medical education, for patients eligible  for  payments  made  by  a  state governmental agency shall be reduced by  three  and  thirty-three  hundredths  percent  to  encourage improved  productivity  and efficiency. The facility will be eligible to receive the financial incentives for the physician  specialty  weighting incentive   towards  primary  care  pursuant  to  subparagraph  (ii)  of paragraph (a) of subdivision twenty-five of this section.   * NB Effective until December 31, 2023   * (k) for facilities designated by the federal  department  of  health and  human services as an exempt acute care children's hospital, payment effective January first, nineteen hundred ninety-four will be based upon a hospital specific case payment amount inclusive of high cost and  high length  of  stay  outlier  costs. The nineteen hundred eighty-seven base year  cost,  trended,  volume  adjusted  and  case  mix  adjusted  where applicable  to  nineteen hundred ninety-two, trended will be utilized to determine the rate of payment effective January first, nineteen  hundred ninety-four.  (i)  Commencing  April first, nineteen hundred ninety-six through July thirty-first, nineteen hundred ninety-six, the operating cost  component of  rates of payment, excluding any operating cost components related to direct and indirect expenses of graduate medical education for  patients eligible  for  payments  made  by  a  state governmental agency shall be reduced by five percent; and  (ii) commencing August  first,  nineteen  hundred  ninety-six  through March  thirty-first,  nineteen  hundred  ninety-seven the operating cost component of rates of payment, excluding any operating  cost  components related  to  direct and indirect expenses of graduate medical education, for patients eligible for payments made by a state  governmental  agency shall be reduced by two and five-tenths percent; and  (iii)  commencing  April  first, nineteen hundred ninety-seven through March thirty-first, nineteen hundred  ninety-nine  and  commencing  July first,  nineteen  hundred  ninety-nine  through  March thirty-first, two thousand, the operating cost component of rates  of  payment,  excluding any operating cost components related to direct and indirect expenses of graduate medical education, for patients eligible for payments made by a state  governmental  agency  shall  be reduced by three and thirty-three hundredths percent to encourage improved  productivity  and  efficiency. The  facility  will  be eligible to receive the financial incentives for the  physician  specialty  weighting  incentive  towards  primary   care pursuant   to   subparagraph   (ii)  of  paragraph  (a)  of  subdivision twenty-five of this section.   * NB Effective and expires December 31, 2023   * (k) for facilities designated by the federal  department  of  health and  human services as an exempt acute care children's hospital, payment  effective January first, nineteen hundred ninety-four will be based upon a hospital specific case payment amount inclusive of high cost and  high length  of  stay  outlier  costs. The nineteen hundred eighty-seven base year  cost,  trended,  volume  adjusted  and  case  mix  adjusted  where applicable to nineteen hundred ninety-two, trended will be  utilized  to determine  the rate of payment effective January first, nineteen hundred ninety-four. The facility will be  eligible  to  receive  the  financial incentives  for  the  physician  specialty  weighting  incentive towards primary  care  pursuant  to  subparagraph  (ii)  of  paragraph  (a)   of subdivision twenty-five of this section.   * NB Effective December 31, 2023   * NB There are 2 par (k)'s  (l)  Notwithstanding  any  inconsistent  provision of this section and subject to the availability of federal financial participation, rates of payment  by  governmental  agencies  for  general  hospitals  which  are certified  by  the  office of alcoholism and substance abuse services to provide inpatient  detoxification  and  withdrawal  services  and,  with regard  to  inpatient  services  provided  to patients discharged on and after December first, two thousand eight and who are determined to be in diagnosis-related groups as defined by the commissioner and published on the New York state department of health website, shall be made on a  per diem basis in accordance with the following:  (i)  for  the  period December first, two thousand eight through March thirty-first, two thousand nine, seventy-five percent of  the  operating cost  component  of  such  rates of payments shall reflect the operating cost component of rates of payment effective for December  thirty-first, two  thousand seven, as adjusted for inflation pursuant to paragraph (c) of subdivision ten  of  this  section,  as  otherwise  modified  by  any applicable statutes, and twenty-five percent of such rates shall reflect the use of two thousand six operating costs as reported by each facility to  the  department  prior  to  two  thousand  eight  and as computed in accordance with the provisions of subparagraph (iv) of this paragraph;  (ii) for the period April  first,  two  thousand  nine  through  March thirty-first,  two thousand ten, thirty-seven and five tenths percent of the operating cost component of such rates of payment shall reflect  the operating   cost  component  of  rates  of  payment  effective  December thirty-first, two thousand seven, as adjusted for inflation pursuant  to paragraph  (c) of subdivision ten of this section, as otherwise modified by any applicable statutes, and sixty-two and  five  tenths  percent  of such  rates  of  payment  shall  reflect  the  use  of  two thousand six operating costs as reported by each facility to the department prior  to two  thousand eight and as computed in accordance with the provisions of subparagraph (iv) of this paragraph;  (iii) for periods on and after April  first,  two  thousand  ten,  one hundred percent of the operating cost component of such rates of payment shall reflect the use of two thousand six operating costs as reported to the department prior to two thousand eight and as computed in accordance with the provisions of subparagraph (iv) of this paragraph.  (iv)  rates  of payment computed in accordance with this paragraph and reflecting the use of two thousand six base year operating  costs  shall be in accord with the following, provided, however that the commissioner may  establish  criteria  under  which  reimbursement may be provided at higher percentages and for longer periods.  (A) For each of the regions within the state as  described  in  clause (E)  of  this  subparagraph the commissioner shall determine the average per diem cost incurred by general hospitals in that  region  subject  to the  provisions  of  this  paragraph with regard to inpatients requiring medically managed detoxification  services,  as  defined  by  applicable  regulations  promulgated by the office of alcoholism and substance abuse services. In determining such costs the commissioner shall  utilize  two thousand  six  costs and statistics as reported by such hospitals to the department prior to two thousand eight.  (B)  Per  diem  payments  for  inpatients  requiring medically managed inpatient detoxification services shall reflect one hundred  percent  of the   per   diem  amounts  computed  pursuant  to  clause  (A)  of  this subparagraph for the applicable region in which the facility is  located and  as  trended forward to adjust for inflation, provided however, that such payments shall be reduced by fifty percent for  any  such  services provided  on or after the sixth day of services through the tenth day of services, and further provided that no payments shall be  made  for  any services provided on or after the eleventh day.  (C)  Per  diem  payments for inpatients requiring medically supervised withdrawal services, as defined by applicable regulations promulgated by the office of alcoholism and substance abuse services, shall reflect one hundred percent of the per diem amounts computed pursuant to clause  (A) of  this subparagraph for the applicable region in which the facility is located for the period January first, two thousand nine through December thirty-first, two thousand nine, and as trended forward  to  adjust  for inflation,  and  shall  reflect  seventy-five  percent  of such per diem amounts for periods on and after January first,  two  thousand  ten,  as trended  forward  to  adjust for inflation, provided, however, that such payments shall be reduced by fifty percent for any services provided  on or  after  the  sixth day of services through the tenth day of services, and further provided that no payments shall be  made  for  any  services provided on and after the eleventh day.  (D)  Per  diem  payments for inpatients placed in observation beds, as defined  by  applicable  regulations  promulgated  by  the   office   of alcoholism  and  substance abuse services, shall be at the same level as would be paid pursuant  to  clause  (A)  of  this  paragraph,  provided, however,  that  such  payments shall not apply for more than two days of care, after which payments  for  such  inpatients  shall  reflect  their designation   as   requiring  either  medically  managed  detoxification services  or  medically  supervised  withdrawal  services,  and  further provided  that days of care provided in such observation beds shall, for reimbursement purposes, be fully reflected in  the  computation  of  the initial  five  days  of care as set forth in clauses (A) and (B) of this subparagraph.  (E) For the purposes of this paragraph, the regions of the state shall be as follows:  (I) New York city, consisting of the  counties  of  Bronx,  New  York, Kings, Queens and Richmond;  (II) Long Island, consisting of the counties of Nassau and Suffolk;  (III)  Northern  metropolitan, consisting of the counties of Columbia, Delaware, Dutchess,  Orange,  Putnam,  Rockland,  Sullivan,  Ulster  and Westchester;  (IV)  Northeast, consisting of the counties of Albany, Clinton, Essex, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington;  (V) Utica/Watertown, consisting of the counties of Franklin, Herkimer, Lewis, Oswego, Otsego, St. Lawrence, Jefferson,  Chenango,  Madison  and Oneida;  (VI)  Central,  consisting of the counties of Broome, Cayuga, Chemung, Cortland, Onondaga, Schuyler, Seneca, Steuben, Tioga and Tompkins;  (VII) Rochester, consisting of Monroe, Ontario, Livingston, Wayne  and Yates;  (VIII)  Western,  consisting of the counties of Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming.  (F) Capital cost reimbursement for general hospitals otherwise subject to  the  provisions  of  this  paragraph  shall  remain  subject  to the provisions of subdivision eight of this section.  (v) the commissioner may promulgate regulations,  including  emergency regulations,  providing  for  an  update  of  the  base  year  costs and statistics used to compute rates of payment pursuant to this  paragraph, provided,  however,  that  such  base  year  update shall take effect no earlier than April first, two thousand fifteen,  and  provided  further, however,  that  the  commissioner  may  make  such  adjustments  to such utilization and to the  methodology  for  computing  such  rates  as  is necessary  to  achieve  no  aggregate,  net  growth  in overall Medicaid expenditures related to  such  rates,  as  compared  to  such  aggregate expenditures  from  the prior year. In determining the updated base year to be utilized pursuant to this  subparagraph,  the  commissioner  shall take  into account the base year determined in accordance with paragraph (c) of subdivision thirty-five of this section.   5.  Reimbursable  inpatient  operating   cost   component.   (a)   The reimbursable  inpatient  operating cost component of case based rates of payment per  diagnosis-related  group  for  general  hospital  inpatient hospital  services  shall  be  the  product  of the average reimbursable inpatient operating cost per discharge  determined  in  accordance  with paragraph  (b)  of  this subdivision, adjusted by a third-party payor of hospital  services  for  uncovered  services  by  such  payor,  and  the weighting  factors  determined  in  accordance  with  paragraph  (c)  of subdivision three of this section.  (b) (i) For the rate year January first, nineteen hundred eighty-eight through December thirty-first, nineteen  hundred  eighty-eight,  average reimbursable inpatient operating cost per discharge shall be a composite sum   of   no  less  than  ninety  percent  of  the  general  hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per discharge determined in accordance with paragraph (a) of subdivision six of this section and a percentage amount not to exceed ten percent of the general   hospital's   group  category  average  inpatient  reimbursable operating cost per  discharge  (price)  determined  in  accordance  with paragraph  (a)  of  subdivision  seven  of  this  section  such that the composite sum equals one hundred percent.  (ii) For the rate year  commencing  January  first,  nineteen  hundred eighty-nine, average reimbursable inpatient operating cost per discharge shall  be  a  composite  sum of no less than seventy-five percent of the general  hospital's  hospital-specific  average  reimbursable  inpatient operating cost per discharge determined in accordance with paragraph (a) of subdivision six of this section and a percentage amount not to exceed twenty-five  percent  of  the  general hospital's group category average inpatient reimbursable operating cost per discharge  (price)  determined in  accordance  with paragraph (a) of subdivision seven of this section, such that the composite sum equals one hundred percent.  (iii) Except as provided in  clause  (C)  of  this  subparagraph,  for annual rate years commencing on or after January first, nineteen hundred ninety,  average  reimbursable  inpatient  operating  cost per discharge shall be a composite sum of no  less  than  forty-five  percent  of  the general  hospital's  hospital-specific  average  reimbursable  inpatient operating cost per discharge determined in accordance with paragraph (a) of subdivision six of this section and a percentage amount not to exceed fifty-five percent of the  general  hospital's  group  category  average inpatient  reimbursable  operating cost per discharge (price) determined  in accordance with paragraph (a) of subdivision seven of  this  section, such that the composite sum equals one hundred percent.   ** (A)  Except  as  provided  in  clause  (B) of this subparagraph and subparagraph (iv) of this paragraph, for annual rate years commencing on or after January first, nineteen hundred  ninety,  average  reimbursable inpatient  operating  cost  per discharge shall be a composite sum of no less than forty-five percent of the general hospital's hospital-specific average reimbursable inpatient operating cost per  discharge  determined in  accordance with paragraph (a) of subdivision six of this section and a percentage amount not to exceed  fifty-five  percent  of  the  general hospital's  group category average inpatient reimbursable operating cost per discharge (price) determined in accordance  with  paragraph  (a)  of subdivision  seven  of  this section, such that the composite sum equals one hundred percent.   ** NB There are 2 clause (A)'s   ** (A) Except as provided in clauses (B) and (C) of this  subparagraph and  subparagraphs (iv), (v) and (vi) of this paragraph, for annual rate years commencing on or after January  first,  nineteen  hundred  ninety, average  reimbursable  inpatient operating cost per discharge shall be a composite sum  of  no  less  than  forty-five  percent  of  the  general hospital's  hospital-specific  average  reimbursable inpatient operating cost per discharge  determined  in  accordance  with  paragraph  (a)  of subdivision  six  of  this section and a percentage amount not to exceed fifty-five percent of the  general  hospital's  group  category  average inpatient  reimbursable  operating cost per discharge (price) determined in accordance with paragraph (a) of subdivision seven of  this  section, such that the composite sum equals one hundred percent.   ** NB Effective until December 31, 2023   ** (A)  Except  as  provided  in  clause (B) of this subparagraph, for annual rate years commencing on or after January first, nineteen hundred ninety, average reimbursable  inpatient  operating  cost  per  discharge shall  be  a  composite  sum  of  no less than forty-five percent of the general  hospital's  hospital-specific  average  reimbursable  inpatient operating cost per discharge determined in accordance with paragraph (a) of subdivision six of this section and a percentage amount not to exceed fifty-five  percent  of  the  general  hospital's group category average inpatient reimbursable operating cost per discharge  (price)  determined in  accordance  with paragraph (a) of subdivision seven of this section, such that the composite sum equals one hundred percent.   ** NB Effective December 31, 2023   ** NB There are 2 clause (A)'s   * (B) For  discharges  on  or  after  April  first,  nineteen  hundred ninety-five for purposes of reimbursement of inpatient hospital services for  patients  eligible for payments made by state governmental agencies assigned to one of the twenty most common diagnosis-related  groups  for all general hospitals, the average reimbursable inpatient operating cost per discharge of a general hospital shall be the lower of (I) the amount determined  in  accordance  with clause (A) of this subparagraph or (II) the average amount determined in accordance  with  clause  (A)  of  this subparagraph  for  all  general hospitals in the group category to which the hospital is  assigned.  The  twenty  most  common  diagnosis-related groups  shall  be determined using discharge data for the year two years prior  to  the  rate  year  for   all   general   hospitals,   excluding beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare) and patients assigned to diagnosis related groups  for  human immunodeficiency  virus  (HIV)  infection,  acquired  immune  deficiency syndrome,  alcohol/drug  use  or  alcohol/drug  induced  organic  mental disorders, and exempt unit or exempt hospital patients.    * NB Expired March 31, 2011   * (C)  (I)  For  discharges  on  or after July first, two thousand six through December thirty-first, two thousand  six,  and  subject  to  the availability  of  federal  financial  participation, rates of payment by state governmental agencies  to  Westchester  medical  center  shall  be increased  by  an  aggregate  amount  of  twenty-five million dollars to assist the medical center to  maintain  critically  needed  health  care services.  (II)  For  discharges  on  or  after January first, two thousand seven through December thirty-first, two thousand seven, and  subject  to  the availability  of  federal  financial  participation, rates of payment by state governmental agencies  to  Westchester  medical  center  shall  be increased  by  an  aggregate  amount  of  twenty-five million dollars to assist the medical center to  maintain  critically  needed  health  care services.  (III)  For  discharges  on  or after January first, two thousand eight through December thirty-first, two thousand eight, and  subject  to  the availability  of  federal  financial  participation, rates of payment by state governmental agencies  to  Westchester  medical  center  shall  be increased  by  an  aggregate  amount  of  twenty-five million dollars to assist the medical center to  maintain  critically  needed  health  care services.   * NB Expired March 31, 2011   * (iv)  for  discharges  on  or  after  April  first, nineteen hundred ninety-six for purposes of reimbursement of inpatient hospital  services for  patients eligible for payments made by state governmental agencies, the average reimbursable inpatient operating cost  per  discharge  of  a general hospital shall be the sum of:  (A)   the   amount   determined  in  accordance  with  clause  (B)  of subparagraph (iii) of this paragraph,  excluding  the  value  of  direct medical  education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of  this  section,  reflected  in  the  general hospital's  hospital-specific  average  reimbursable inpatient operating cost per discharge and group  category  average  inpatient  reimbursable operating  cost  per  discharge,  and  excluding the value of forty-five percent of the  indirect  medical  education  expenses,  as  defined  in subparagraph (ii) of paragraph (c) of subdivision seven of this section, reflected   in   the   general   hospital's  hospital  specific  average reimbursable inpatient operating cost per discharge, and  excluding  the value  of  fifty-five percent of the indirect medical education expenses reflected in a  general  hospital's  group  category  average  inpatient reimbursable operating cost per discharge in accordance with subdivision twenty-five of this section as amended;  (B)  minus  five  percent  of the amount determined in accordance with clause (A) of this subparagraph;  (C) plus the value of direct medical education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of this  section, reflected   in   the   general   hospital's   hospital-specific  average reimbursable inpatient operating cost per discharge and  group  category average inpatient reimbursable operating cost per discharge;  (D)  minus  five  percent  of  the  costs of hospital based physicians reflected  in  the  direct  medical  education  amount   determined   in accordance with clause (C) of this subparagraph;  (E)  plus  the  value  of  forty-five  percent of the indirect medical education expenses, as defined in subparagraph (ii) of paragraph (c)  of subdivision  seven  of this section, reflected in the general hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per discharge; and  (F)  plus  the  value  of  fifty-five  percent of the indirect medical education expenses reflected in the general  hospital's  group  category average  inpatient  operating  cost  per  discharge  in  accordance with subdivision twenty-five of this section as amended.   * NB There are 3 subpar (iv)'s   * (iv)  for  discharges  on  or  after  April  first, nineteen hundred ninety-six for purposes of reimbursement of inpatient hospital  services for  patients eligible for payments made by state governmental agencies, the average reimbursable inpatient operating cost  per  discharge  of  a general hospital shall to encourage improved productivity and efficiency be the sum of:  (A)   the   amount   determined  in  accordance  with  clause  (B)  of subparagraph (iii) of this paragraph,  excluding  the  value  of  direct medical  education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of  this  section,  reflected  in  the  general hospital's  hospital-specific  average  reimbursable inpatient operating cost per discharge and group  category  average  inpatient  reimbursable operating  cost  per  discharge,  and  excluding the value of forty-five percent of the  indirect  medical  education  expenses,  as  defined  in subparagraph (ii) of paragraph (c) of subdivision seven of this section, reflected   in   the   general   hospital's  hospital  specific  average reimbursable inpatient operating cost per discharge, and  excluding  the value  of  fifty-five percent of the indirect medical education expenses reflected in a  general  hospital's  group  category  average  inpatient reimbursable operating cost per discharge in accordance with subdivision twenty-five of this section as amended;  (B)  minus  five  percent  of the amount determined in accordance with clause (A) of this subparagraph;  (C) plus the value of direct medical education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of this  section, reflected   in   the   general   hospital's   hospital-specific  average reimbursable inpatient operating cost per discharge and  group  category average inpatient reimbursable operating cost per discharge;  (D)  minus  five  percent  of  the  costs of hospital based physicians reflected  in  the  direct  medical  education  amount   determined   in accordance with clause (C) of this subparagraph;  (E)  plus  the  value  of  forty-five  percent of the indirect medical education expenses, as defined in subparagraph (ii) of paragraph (c)  of subdivision  seven  of this section, reflected in the general hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per discharge; and  (F)  plus  the  value  of  fifty-five  percent of the indirect medical education expenses reflected in the general  hospital's  group  category average  inpatient  operating  cost  per  discharge  in  accordance with subdivision twenty-five of this section as amended.   * NB There are 3 subpar (iv)'s   * (iv) for discharges  on  or  after  April  first,  nineteen  hundred ninety-six  through  July  thirty-first, nineteen hundred ninety-six for purposes of reimbursement of inpatient hospital  services  for  patients eligible  for  payments made by state governmental agencies, the average reimbursable  inpatient  operating  cost  per  discharge  of  a  general hospital  shall,  to  encourage improved productivity and efficiency, be the sum of:  (A)  the  amount  determined  in  accordance  with   clause   (B)   of subparagraph  (iii)  of  this  paragraph,  excluding the value of direct medical education expenses, as defined in subparagraph (i) of  paragraph (c)  of  subdivision  seven  of  this  section, reflected in the general hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per  discharge  and  group category average inpatient reimbursable operating cost per discharge, and  excluding  the  value  of  forty-five percent  of  the  indirect  medical  education  expenses,  as defined in subparagraph (ii) of paragraph (c) of subdivision seven of this section, reflected   in   the   general   hospital's  hospital  specific  average reimbursable inpatient operating cost per discharge, and  excluding  the value  of  fifty-five percent of the indirect medical education expenses reflected in a  general  hospital's  group  category  average  inpatient reimbursable operating cost per discharge in accordance with subdivision twenty-five of this section as amended;  (B)  minus  five  percent  of the amount determined in accordance with clause (A) of this subparagraph;  (C) plus the value of direct medical education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of this  section, reflected   in   the   general   hospital's   hospital-specific  average reimbursable inpatient operating cost per discharge and  group  category average inpatient reimbursable operating cost per discharge;  (D)  minus  five  percent  of  the  costs of hospital based physicians reflected  in  the  direct  medical  education  amount   determined   in accordance with clause (C) of this subparagraph;  (E)  plus  the  value  of  forty-five  percent of the indirect medical education expenses, as defined in subparagraph (ii) of paragraph (c)  of subdivision  seven  of this section, reflected in the general hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per discharge; and  (F)  plus  the  value  of  fifty-five  percent of the indirect medical education expenses reflected in the general  hospital's  group  category average  inpatient  operating  cost  per  discharge  in  accordance with subdivision twenty-five of this section as amended.   * NB Expires December 31, 2023   * NB There are 3 subpar (iv)'s   * (v) for discharges  on  or  after  August  first,  nineteen  hundred ninety-six through March thirty-first, nineteen hundred ninety-seven for purposes  of  reimbursement  of inpatient hospital services for patients eligible for payments made by state governmental agencies,  the  average reimbursable  inpatient  operating  cost  per  discharge  of  a  general hospital shall, to encourage improved productivity  and  efficiency,  be the sum of:  (A)   the   amount   determined  in  accordance  with  clause  (B)  of subparagraph (iii) of this paragraph,  excluding  the  value  of  direct medical  education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of  this  section,  reflected  in  the  general hospital's  hospital-specific  average  reimbursable inpatient operating cost per discharge and group  category  average  inpatient  reimbursable operating  cost  per  discharge,  and  excluding the value of forty-five percent of the  indirect  medical  education  expenses,  as  defined  in subparagraph (ii) of paragraph (c) of subdivision seven of this section, reflected   in   the   general   hospital's  hospital  specific  average reimbursable inpatient operating cost per discharge, and  excluding  the value  of  fifty-five percent of the indirect medical education expenses reflected in a  general  hospital's  group  category  average  inpatient reimbursable operating cost per discharge in accordance with subdivision twenty-five of this section as amended;  (B)  minus  two  and  five-tenths  percent of the amount determined in accordance with clause (A) of this subparagraph;  (C) plus the value of direct medical education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of this  section, reflected   in   the   general   hospital's   hospital-specific  average  reimbursable inpatient operating cost per discharge and  group  category average inpatient reimbursable operating cost per discharge;  (D)  minus  two and five-tenths percent of the costs of hospital based physicians reflected in the direct medical education  amount  determined in accordance with clause (C) of this subparagraph;  (E)  plus  the  value  of  forty-five  percent of the indirect medical education expenses, as defined in subparagraph (ii) of paragraph (c)  of subdivision  seven  of this section, reflected in the general hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per discharge; and  (F)  plus  the  value  of  fifty-five  percent of the indirect medical education expenses reflected in the general  hospital's  group  category average  inpatient  operating  cost  per  discharge  in  accordance with subdivision twenty-five of this section as amended.   * NB Expires December 31, 2023   * (vi) for discharges  on  or  after  April  first,  nineteen  hundred ninety-seven  through  March  thirty-first, nineteen hundred ninety-nine and for discharges on or after July first, nineteen hundred  ninety-nine through  March thirty-first, two thousand and for discharges on or after April first, two thousand through March thirty-first, two thousand  five and  for  discharges  on or after April first, two thousand five through March thirty-first, two thousand six, and for  discharges  on  or  after April  first,  two thousand six through March thirty-first, two thousand seven, and for discharges on or after April first,  two  thousand  seven through  March thirty-first, two thousand nine, and for discharges on or after April first, two thousand nine  through  March  thirty-first,  two thousand  eleven,  for  purposes  of reimbursement of inpatient hospital services for patients eligible for payments made by  state  governmental agencies,   the   average  reimbursable  inpatient  operating  cost  per discharge  of  a  general  hospital   shall,   to   encourage   improved productivity and efficiency, be the sum of:  (A)   the   amount   determined  in  accordance  with  clause  (B)  of subparagraph (iii) of this paragraph,  excluding  the  value  of  direct medical  education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of  this  section,  reflected  in  the  general hospital's  hospital-specific  average  reimbursable inpatient operating cost per discharge and group  category  average  inpatient  reimbursable operating  cost  per  discharge,  and  excluding the value of forty-five percent of the  indirect  medical  education  expenses,  as  defined  in subparagraph (ii) of paragraph (c) of subdivision seven of this section, reflected   in   the   general   hospital's   hospital-specific  average reimbursable inpatient operating cost per discharge, and  excluding  the value  of  fifty-five percent of the indirect medical education expenses reflected in a  general  hospital's  group  category  average  inpatient reimbursable operating cost per discharge in accordance with subdivision twenty-five of this section as amended;  (B)  minus  three  and  thirty-three  hundredths percent of the amount determined in accordance with clause (A) of this subparagraph;  (C) plus the value of direct medical education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of this  section, reflected   in   the   general   hospital's   hospital-specific  average reimbursable inpatient operating cost per discharge and  group  category average inpatient reimbursable operating cost per discharge;  (D)  minus  three  and thirty-three hundredths percent of the costs of hospital based physicians reflected  in  the  direct  medical  education amount determined in accordance with clause (C) of this subparagraph;  (E)  plus  the  value  of  forty-five  percent of the indirect medical education expenses, as defined in subparagraph (ii) of paragraph (c)  of  subdivision  seven  of this section, reflected in the general hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per discharge; and  (F)  plus  the  value  of  fifty-five  percent of the indirect medical education expenses reflected in the general  hospital's  group  category average  inpatient  operating  cost  per  discharge  in  accordance with subdivision twenty-five of this section as amended.   * NB Effective until December 31, 2023   * (vi) for discharges  on  or  after  April  first,  nineteen  hundred ninety-seven  through  March  thirty-first, nineteen hundred ninety-nine and for discharges on or after July first, nineteen hundred  ninety-nine through  March  thirty-first, two thousand for purposes of reimbursement of inpatient hospital services for patients eligible for  payments  made by  state  governmental  agencies,  the  average  reimbursable inpatient operating cost per discharge of a general hospital shall,  to  encourage improved productivity and efficiency, be the sum of:  (A)   the   amount   determined  in  accordance  with  clause  (B)  of subparagraph (iii) of this paragraph,  excluding  the  value  of  direct medical  education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of  this  section,  reflected  in  the  general hospital's  hospital-specific  average  reimbursable inpatient operating cost per discharge and group  category  average  inpatient  reimbursable operating  cost  per  discharge,  and  excluding the value of forty-five percent of the  indirect  medical  education  expenses,  as  defined  in subparagraph (ii) of paragraph (c) of subdivision seven of this section, reflected   in   the   general   hospital's   hospital-specific  average reimbursable inpatient operating cost per discharge, and  excluding  the value  of  fifty-five percent of the indirect medical education expenses reflected in a  general  hospital's  group  category  average  inpatient reimbursable operating cost per discharge in accordance with subdivision twenty-five of this section as amended;  (B)  minus  three  and  thirty-three  hundredths percent of the amount determined in accordance with clause (A) of this subparagraph;  (C) plus the value of direct medical education expenses, as defined in subparagraph (i) of paragraph (c) of subdivision seven of this  section, reflected   in   the   general   hospital's   hospital-specific  average reimbursable inpatient operating cost per discharge and  group  category average inpatient reimbursable operating cost per discharge;  (D)  minus  three  and thirty-three hundredths percent of the costs of hospital based physicians reflected  in  the  direct  medical  education amount determined in accordance with clause (C) of this subparagraph;  (E)  plus  the  value  of  forty-five  percent of the indirect medical education expenses, as defined in subparagraph (ii) of paragraph (c)  of subdivision  seven  of this section, reflected in the general hospital's hospital-specific average  reimbursable  inpatient  operating  cost  per discharge; and  (F)  plus  the  value  of  fifty-five  percent of the indirect medical education expenses reflected in the general  hospital's  group  category average  inpatient  operating  cost  per  discharge  in  accordance with subdivision twenty-five of this section as amended.   * NB Effective and expires December 31, 2023   * (c) Notwithstanding any  inconsistent  provision  of  this  section, commencing   July  first,  nineteen  hundred  ninety-six  through  March thirty-first, nineteen hundred  ninety-nine  and  July  first,  nineteen hundred  ninety-nine  through March thirty-first, two thousand and April first, two thousand through March thirty-first, two  thousand  five  and for  periods  on  and after April first, two thousand five through March thirty-first, two thousand six, and  for  periods  on  and  after  April  first,  two thousand six through March thirty-first, two thousand seven, and for periods on and after April first,  two  thousand  seven  through March  thirty-first,  two  thousand  nine,  and for periods on and after April  first, two thousand nine through March thirty-first, two thousand eleven, rates of payment for a general hospital  for  patients  eligible for  payments  made  by  state  governmental  agencies  shall be further reduced by the  commissioner  to  encourage  improved  productivity  and efficiency by providers by a factor determined as follows:  (i)  an  aggregate  reduction  shall  be  calculated  for each general hospital commencing July  first,  nineteen  hundred  ninety-six  through March   thirty-first,  nineteen  hundred  ninety-nine  and  July  first, nineteen hundred ninety-nine through March  thirty-first,  two  thousand and  April  first, two thousand through March thirty-first, two thousand five and for periods on and after April first, two thousand five through March thirty-first, two thousand six, and for periods on and after April first, two thousand six through March thirty-first, two thousand  seven, and  for  periods  on  and after April first, two thousand seven through March thirty-first, two thousand nine, and  for  periods  on  and  after April  first, two thousand nine through March thirty-first, two thousand eleven,  as  the  result  of  (A)  eighty-nine  million  dollars  on  an annualized  basis  for each year, multiplied by (B) the ratio of patient days for patients eligible  for  payments  made  by  state  governmental agencies  provided  in a base year two years prior to the rate year by a general hospital, divided by the total of such patient days  summed  for all general hospitals; and  (ii)  (A)  the  result for each general hospital shall be allocated to units within such hospital exempt from case based rates of payment based on the ratio of such patient days provided in the  exempt  unit  to  the total of such patient days provided by the general hospital, and (B) the result  divided  by such patient days provided in the exempt unit, for a per diem unit of service reduction in rates of payment for  such  exempt unit  for  patients  eligible  for  payments  made by state governmental agencies for such general hospital; and  (iii) any amount not allocated to exempt units  shall  be  divided  by case  based  discharges (or for exempt hospitals by patient days) in the base year two years prior to the rate year  for  patients  eligible  for payments  made  by  state  governmental agencies, for a per case (or for exempt hospitals a per diem) unit  of  service  reduction  in  rates  of payment  for  patients  eligible for payments made by state governmental agencies for such general hospital.   * NB Effective until December 31, 2023   * (c) Notwithstanding any  inconsistent  provision  of  this  section, commencing   July  first,  nineteen  hundred  ninety-six  through  March thirty-first, nineteen hundred  ninety-nine  and  July  first,  nineteen hundred  ninety-nine  through  March thirty-first, two thousand rates of payment for a general hospital for patients eligible for  payments  made by   state  governmental  agencies  shall  be  further  reduced  by  the commissioner  to  encourage  improved  productivity  and  efficiency  by providers by a factor determined as follows:  (i)  an  aggregate  reduction  shall  be  calculated  for each general hospital commencing July first,   nineteen  hundred  ninety-six  through March   thirty-first,  nineteen  hundred  ninety-nine  and  July  first, nineteen hundred ninety-nine through March thirty-first, two thousand as the result of (A) eighty-nine million dollars on an annualized basis for each year, multiplied by (B) the ratio  of  patient  days  for  patients eligible  for payments made by state governmental agencies provided in a base year two years prior to  the  rate  year  by  a  general  hospital,  divided  by  the  total  of  such  patient  days  summed for all general hospitals; and  (ii)  (A)  the  result for each general hospital shall be allocated to units within such hospital exempt from case based rates of payment based on the ratio of such patient days provided in the  exempt  unit  to  the total of such patient days provided by the general hospital, and (B) the result  divided  by such patient days provided in the exempt unit, for a per diem unit of service reduction in rates of payment for  such  exempt unit  for  patients  eligible  for  payments  made by state governmental agencies for such general hospital; and  (iii) any amount not allocated to exempt units  shall  be  divided  by case  based  discharges (or for exempt hospitals by patient days) in the base year two years prior to the rate year  for  patients  eligible  for payments  made  by  state  governmental agencies, for a per case (or for exempt hospitals a per diem) unit  of  service  reduction  in  rates  of payment  for  patients  eligible for payments made by state governmental agencies for such general hospital.   * NB Effective and expires December 31, 2023   6. Operating costs. (a) A general hospital's hospital-specific average reimbursable inpatient operating cost per discharge shall be  determined in  accordance  with  rules  and  regulations adopted by the council and approved by  the  commissioner  based  on  the  hospital's  reimbursable inpatient  operating  cost  base determined in accordance with paragraph (d) of subdivision one of this  section;  adjusted  in  accordance  with paragraph  (b)  of  this  subdivision  to  reflect  exceptions  to  case payments; and projected to the applicable rate period by a trend  factor determined  in  accordance  with  subdivision  ten  of this section; and increased in accordance  with  subparagraphs  (i),  (iii)  and  (iv)  of paragraph  (e)  of  subdivision  one  of this section to reflect special additional inpatient operating costs; and adjusted  in  accordance  with subparagraphs (i), (ii) and (iv) of paragraph (c) of this subdivision to reflect  modifications  to  case  payments;  and standardized to reflect nineteen hundred eighty-seven hospital case mix.  A  general  hospital's hospital-specific  average  reimbursable  inpatient  operating  cost per discharge shall be  adjusted  on  a  payor  category  basis  to  reflect allocation  of  malpractice  insurance  costs  in  accordance  with  the methodology developed pursuant to subparagraph (ii) of paragraph (h)  of subdivision eleven of this section.  (b)  In  accordance  with rules and regulations adopted by the council and  approved  by  the  commissioner,  the  commissioner  shall   adjust reimbursable   inpatient  operating  costs  and  discharges  to  exclude operating costs and statistics related to specialized hospital  services for  which  an alternative reimbursement methodology is adopted pursuant to paragraph (e) or (g) of subdivision four of this  section,  a  factor for  operating costs of patients who required an alternate level of care in accordance with paragraph (h) of subdivision four of this section and the  operating  costs  and  statistics  of  AIDS  patients  pursuant  to paragraph (i) of subdivision four of this section if effective.  (c)  In  accordance  with rules and regulations adopted by the council and  approved  by  the  commissioner,  the  commissioner  shall   adjust weighting  factors  developed  pursuant  to paragraph (c) of subdivision three of this section and reimbursable  inpatient  operating  costs  and statistics  on  which  case payment rates are based to take into account the provisions for additional payments in accordance with paragraph (a), (b), (c) or (d) of subdivision four  of  this  section.  The  rules  and regulations  are  to  be  designed  to identify an estimate of costs and statistics as if the payment methodology effective  for  the  applicable rate  period including payment based on the higher of high-cost outliers  or long-stay outliers was in effect during the period used to  establish such costs and statistics to accomplish the following:  (i)   an   estimate  of  costs  for  inpatient  services  to  patients transferred to another general hospital  receiving  case  payment  rates pursuant  to  paragraph (a) of subdivision four of this section shall be eliminated from reimbursable inpatient  operating  costs  considering  a transfer  patient  cost  conversion  factor determined based on nineteen hundred  eighty-five  data  from  a  representative  sample  of  general hospitals;  a  case  mix  neutral acute care cost component of a general hospital's reimbursable inpatient operating  cost  base  per  day  after application  of  the trend factor and the addition of special additional inpatient operating  costs;  transfer  patient  days  incurred  by  such general  hospital in nineteen hundred eighty-seven or the number of such transfer patient days during a recent twelve month period prior  thereto established  by  regulation  for  which  data are available subsequently reconciled by an adjustment to  reflect  nineteen  hundred  eighty-seven data;  and the specific diagnosis-related groups with which the transfer patients are identified. Such costs shall be  eliminated  in  accordance with  rules  and  regulations adopted by the council and approved by the commissioner which shall contain the specific methodology to  adequately identify  the  costs  related to transfer cases. Transfer cases shall be eliminated in computing discharges of  the  transferring  hospital.  The costs  and  discharges  for  transfer  cases  for  each general hospital participating in the determination of the  weighting  factors  shall  be removed before calculating the weighting factors;  (ii)  an  estimate  of  costs  for  the  outlier  portion of inpatient services which would qualify for additional payments as cost outliers in accordance with paragraph (b) of subdivision four of this section  shall be  eliminated  from  reimbursable  inpatient operating costs based on a general hospital's high cost percentage outlier factor,  applied  to  an acute  care  cost  component  of  such  general  hospital's reimbursable inpatient operating cost base after application of the trend factor  and the  addition  of special additional inpatient operating costs. The high cost  percentage  outlier  factor  shall  be  calculated  based   on   a determination   of  the  percentage  of  nineteen  hundred  eighty-seven discharges of patients other than beneficiaries of title  XVIII  of  the federal  social  security  act (medicare) for which the commissioner has complete hospital bill submissions or such discharges  during  a  recent twelve  month  period  prior thereto established by regulation for which hospital bills are available, as follows, (a) for general hospitals that have complete hospital bill submissions for at least ninety  percent  of their  discharges,  a  high cost percentage outlier factor based on such data, and (b) for general hospitals that  have  complete  hospital  bill submissions  for at least eighty percent but less than ninety percent of their discharges, a high cost percentage outlier factor  based  on  such data  plus an additional one-quarter of one percent, and (c) for general hospitals that have complete  bill  submissions  for  less  than  eighty percent  of  their  discharges,  a  high  cost percentage outlier factor determined  based  on  nineteen  hundred   eighty-five   data   from   a representative   sample   of   general   hospitals  plus  an  additional one-quarter of one percent. The calculation of the high cost  percentage outlier  factor  shall  be  subsequently  reconciled by an adjustment to reflect the percentage of such complete hospital  bill  submissions  for such  nineteen  hundred  eighty-seven  discharges  as  submitted  to the commissioner prior to August first, nineteen hundred eighty-eight.   The minimum percentage threshold applicable pursuant to clause (a)  of the  first  paragraph of this subparagraph may be increased to "at least ninety-five percent" and the percentage ceiling applicable  pursuant  to  clause  (b)  of  the  first  paragraph of this subparagraph increased to "less than  ninety-five  percent"  pursuant  to  rules  and  regulations adopted  by  the  council  and approved by the commissioner based upon a study  and  a  report  by  the  commissioner  of  a sample of incomplete discharge records which showed that there was a  significant  difference in  the  value  of  high  cost  outlier  cases  potentially reflected in incomplete records from the value of high cost outlier  cases  reflected in  records  for  which  the  commissioner  has  complete  hospital bill submissions.   The maximum amount to be eliminated on  a  statewide  basis  shall  be three  percent  of the total of nineteen hundred eighty-eight acute care cost components of general  hospital  reimbursable  inpatient  operating costs reimbursed on the case payment system. In the event that the total amount  as  calculated exceeds three percent, the calculated amount will be reduced to three percent by the application of a percentage  computed by  dividing expected outlier costs based on the three percent by actual outlier costs, which shall also be the percentage of outlier costs to be reimbursed in the payment year. The costs for  the  outlier  portion  of cost  outliers  for general hospitals participating in the determination of the weighting factors shall be removed  from  each  diagnosis-related group before determining the weighting factors;   * (iii) an estimate of inpatient costs which are related to a hospital stay  in  excess  of  the  long stay threshold for long stay patients as defined in paragraph (c) of subdivision four of this  section  shall  be eliminated  from  reimbursable  inpatient operating costs in determining group  category   average   inpatient   reimbursable   operating   costs considering  a  long stay patient cost conversion factor, which shall be established at sixty percent provided, however, such long  stay  patient cost  conversion  factor  may  be  revised  for an annual rate period or periods  beginning  on  or  after  January   first,   nineteen   hundred eighty-nine  in  accordance  with  rules  and regulations adopted by the council and approved by the commissioner; a case mix neutral acute  care cost  component of a general hospital's reimbursable inpatient operating cost base per day after application of the trend factor and the addition of special additional inpatient operating costs; long stay patient  days incurred  by  such  general hospital in nineteen hundred eighty-seven or the number of such long stay patient days during a recent  twelve  month period  prior  thereto  established  by  regulation  for  which data are available subsequently reconciled by an adjustment to  reflect  nineteen hundred  eighty-seven  data;  and  the specific diagnosis-related groups with which the long stay patients are identified. The long stay  outlier thresholds shall be determined by adding a sufficient number of standard deviations  to  the mean length of stay for each diagnosis-related group such that it is estimated for rates of payment during the period January first, nineteen  hundred  eighty-eight  through  December  thirty-first, nineteen  hundred  ninety  based  upon nineteen hundred eighty-five data from a representative sample of  general  hospitals  and  for  rates  of payment  during  the  period  January first, nineteen hundred ninety-one through December thirty-first, nineteen hundred ninety-three based  upon nineteen  hundred  eighty-nine  data  from  a  representative  sample of general hospitals and for rates of payment  during  the  period  January first,  nineteen  hundred  ninety-four  through  December  thirty-first, nineteen hundred ninety-nine and periods on and after January first, two thousand  based  upon  nineteen   hundred   ninety-two   data   from   a representative  sample  of  general  hospitals that the costs associated with the portion of hospital stays in excess of the  long  stay  outlier thresholds  do  not  exceed three percent of the total of the acute care cost components of reimbursable inpatient operating costs related to the  determination of case based rates of payment. The costs associated  with the  outlier  portion  of  long  stay outliers for each general hospital participating in the determination of the  weighting  factors  shall  be removed   from  each  diagnosis-related  group  before  calculating  the weighting factors;   * NB Effective until December 31, 2023   * (iii) an estimate of inpatient costs which are related to a hospital stay in excess of the long stay threshold  for  long  stay  patients  as defined  in  paragraph  (c) of subdivision four of this section shall be eliminated from reimbursable inpatient operating  costs  in  determining group   category   average   inpatient   reimbursable   operating  costs considering a long stay patient cost conversion factor, which  shall  be established  at  sixty percent provided, however, such long stay patient cost conversion factor may be revised  for  an  annual  rate  period  or periods   beginning   on   or  after  January  first,  nineteen  hundred eighty-nine in accordance with rules  and  regulations  adopted  by  the council  and approved by the commissioner; a case mix neutral acute care cost component of a general hospital's reimbursable inpatient  operating cost base per day after application of the trend factor and the addition of  special additional inpatient operating costs; long stay patient days incurred by such general hospital in nineteen  hundred  eighty-seven  or the  number  of such long stay patient days during a recent twelve month period prior thereto  established  by  regulation  for  which  data  are available  subsequently  reconciled by an adjustment to reflect nineteen hundred eighty-seven data; and  the  specific  diagnosis-related  groups with  which the long stay patients are identified. The long stay outlier thresholds shall be determined by adding a sufficient number of standard deviations to the mean length of stay for each  diagnosis-related  group such that it is estimated for rates of payment during the period January first,  nineteen  hundred  eighty-eight  through  December thirty-first, nineteen hundred ninety based upon  nineteen  hundred  eighty-five  data from  a  representative  sample  of  general  hospitals and for rates of payment during the period January  first,  nineteen  hundred  ninety-one through  December thirty-first, nineteen hundred ninety-three based upon nineteen hundred  eighty-nine  data  from  a  representative  sample  of general  hospitals  and  for  rates of payment during the period January first,  nineteen  hundred  ninety-four  through  December  thirty-first, nineteen hundred ninety-nine based upon nineteen hundred ninety-two data from  a  representative  sample  of  general  hospitals  that  the costs associated with the portion of hospital stays in excess of the long stay outlier thresholds do not exceed three percent of the total of the acute care cost components of reimbursable inpatient operating  costs  related to  the  determination  of  case  based  rates  of  payment.  The  costs associated with the outlier portion  of  long  stay  outliers  for  each general  hospital  participating  in  the determination of the weighting factors shall  be  removed  from  each  diagnosis-related  group  before calculating the weighting factors;   * NB Effective and expires December 31, 2023   * (iii) an estimate of inpatient costs which are related to a hospital stay  in  excess  of  the  long stay threshold for long stay patients as defined in paragraph (c) of subdivision four of this  section  shall  be eliminated  from  reimbursable  inpatient operating costs in determining group  category   average   inpatient   reimbursable   operating   costs considering  a  long stay patient cost conversion factor, which shall be established at sixty percent provided, however, such long  stay  patient cost  conversion  factor  may  be  revised  for an annual rate period or periods  beginning  on  or  after  January   first,   nineteen   hundred eighty-nine  in  accordance  with  rules  and regulations adopted by the  council and approved by the commissioner; a case mix neutral acute  care cost  component of a general hospital's reimbursable inpatient operating cost base per day after application of the trend factor and the addition of  special additional inpatient operating costs; long stay patient days incurred by such general hospital in nineteen  hundred  eighty-seven  or the  number  of such long stay patient days during a recent twelve month period prior thereto  established  by  regulation  for  which  data  are available  subsequently  reconciled by an adjustment to reflect nineteen hundred eighty-seven data; and  the  specific  diagnosis-related  groups with  which the long stay patients are identified. The long stay outlier thresholds shall be determined by adding a sufficient number of standard deviations to the mean length of stay for each  diagnosis-related  group such that it is estimated for rates of payment during the period January first,  nineteen  hundred  eighty-eight  through  December thirty-first, nineteen hundred ninety based upon  nineteen  hundred  eighty-five  data from  a  representative  sample  of  general  hospitals and for rates of payment during the period January  first,  nineteen  hundred  ninety-one through  December thirty-first, nineteen hundred ninety-three based upon nineteen hundred  eighty-nine  data  from  a  representative  sample  of general  hospitals  and  for  rates of payment during the period January first, nineteen hundred ninety-four  through  June  thirtieth,  nineteen hundred  ninety-six  based  upon nineteen hundred ninety-two data from a representative sample of general hospitals  that  the  costs  associated with  the  portion  of hospital stays in excess of the long stay outlier thresholds do not exceed three percent of the total of  the  acute  care cost components of reimbursable inpatient operating costs related to the determination  of case based rates of payment. The costs associated with the outlier portion of long stay  outliers  for  each  general  hospital participating  in  the  determination  of the weighting factors shall be removed  from  each  diagnosis-related  group  before  calculating   the weighting factors;   * NB Effective December 31, 2023  (iv)  an  estimate  of inpatient costs which are related to short stay patients as defined in paragraph (d) of subdivision four of this section shall  be  eliminated  from  reimbursable  inpatient   operating   costs considering a short stay patient cost conversion factor determined based on  nineteen  hundred  eighty-five  data from a representative sample of general hospitals; a case mix neutral acute care  cost  component  of  a general  hospital's  reimbursable  inpatient operating cost base per day after application of the  trend  factor  and  the  addition  of  special additional  inpatient  operating costs; short stay patient days incurred by such general hospital in nineteen hundred eighty-seven or the  number of  such  short  stay  patient  days during a recent twelve month period prior thereto established by regulation for  which  data  are  available subsequently  reconciled  by  an  adjustment to reflect nineteen hundred eighty-seven data; and the specific diagnosis-related groups with  which the  short  stay patients are identified. Such costs shall be eliminated in accordance with rules and regulations  adopted  by  the  council  and approved   by   the   commissioner  which  shall  contain  the  specific methodology to adequately identify  the  costs  related  to  short  stay patients.  Short  stay cases shall be eliminated in computing discharges of a general hospital. The costs and discharges for short stay cases for each  general  hospital  participating  in  the  determination  of   the weighting  factors  shall  be  removed  before calculating the weighting factors.   7. Operating cost group component.  (a)  A  general  hospital's  group category  average  inpatient  reimbursable  operating cost per discharge (price) shall be a composite factor determined in accordance with  rules  and  regulations adopted by the council and approved by the commissioner based  on  a  group  price  component  determined  in  accordance   with subparagraph  (i) of this paragraph, a hospital-specific price component determined  in  accordance with subparagraph (ii) of this paragraph, and an adjustment in accordance with subparagraph (iii) of this paragraph.  (i) The group  price  component  shall  be  based  on  the  costs  and statistics  of  general  hospitals  in  the  group  category established pursuant to paragraph (b) of this subdivision to which the  hospital  is assigned  by the commissioner to compute a group based average inpatient reimbursable operating  cost  per  discharge  for  the  group  category. General  hospital  costs  and  statistics shall be determined consistent with the methodology to determine hospital-specific average reimbursable inpatient operating cost per discharge pursuant to  subdivision  six  of this   section;   adjusted  to  reflect  additional  cost  increases  in accordance with subparagraph (ii) of paragraph (e) of subdivision one of this   section;   and   adjusted   to   exclude   the   components    of hospital-specific  inpatient  reimbursable  operating  costs  related to education, physician, ambulance services  and  organ  acquisition  costs determined  in  accordance  with  paragraph  (c) of this subdivision and malpractice insurance costs, and the components  of  special  additional inpatient  operating  costs  determined and allocated in accordance with subparagraphs (i), (iii) and (iv) of paragraph (e) of subdivision one of this section associated with cost increases in such costs; and  adjusted to  exclude  the  components  of  special additional inpatient operating costs determined and allocated in accordance with clauses (B), (D), (H), and  (I)  of  subparagraph  (iii)  and  clauses  (A),  (E)  and  (F)  of subparagraph  (iv)  of paragraph (e) of subdivision one of this section; and adjusted to reflect additional modifications  to  case  payments  in accordance  with  subparagraph (iii) of paragraph (c) of subdivision six of  this  section.  The  group  based  average  inpatient   reimbursable operating  costs  computed  for  a general hospital shall be adjusted to reflect  the  hospital-specific   indirect   medical   education   costs percentage  of  such hospital determined in accordance with subparagraph (ii) of paragraph (c) of this subdivision.   Hospital  costs  shall  be  standardized   for   comparison   purposes considering  differences  in wage and wage-related costs levels and such other economic factors, such as a power equalization factor, as  may  be determined  in  accordance  with  rules  and  regulations adopted by the council and approved by the commissioner.  (ii) A hospital-specific price component shall be determined for  each general  hospital  based on such hospital's hospital-specific education, physician, ambulance services and organ acquisition costs determined  in accordance  with  subparagraphs  (i), (iii) and (iv) of paragraph (c) of this subdivision and malpractice insurance costs, and the components  of special additional inpatient operating costs determined and allocated in accordance  with  subparagraphs  (i), (iii) and (iv) of paragraph (e) of subdivision one of this section associated with cost increases  in  such costs,  and  special additional inpatient operating costs determined and allocated  in  accordance  with  clauses  (B),  (D),  (H)  and  (I)   of subparagraph  (iii) and clauses (A), (E) and (F) of subparagraph (iv) of paragraph (e) of subdivision one of this section, as  excluded  pursuant to  subparagraph  (i)  of this paragraph, per discharge, standardized to reflect nineteen hundred eighty-seven hospital case mix.  (iii)  A  general  hospital's   group   category   average   inpatient reimbursable  operating  cost per discharge shall be adjusted on a payor category basis to reflect allocation of malpractice insurance  costs  in accordance  with the methodology developed pursuant to subparagraph (ii) of paragraph (h) of subdivision eleven of this section.  (b)  General  hospital  group  categories  shall  be  established   in accordance  with  rules  and  regulations  adopted  by  the  council and approved by the commissioner for purposes of  computing  group  category average inpatient reimbursable operating cost per discharge considering, but  not  limited  to,  factors  such as hospital size, hospital medical education activity, teaching status  and  geographic  divisions  of  the state.  (c)  Education,  physician,  ambulance  services and organ acquisition costs shall include:  (i) direct medical education expenses,  defined  as  the  reimbursable costs  of  residents, fellows, and supervising physicians, combined with the costs of hospital based physicians;  (ii) indirect medical education expenses, defined as  an  estimate  of the  costs,  other  than  direct  costs,  of  educational  activities in teaching hospitals attributable to factors including but not limited  to increased  overhead,  more  severely  ill  patients  and the tendency of residents to provide more tests than  experienced  licensed  physicians. For   the   rate   period  beginning  January  first,  nineteen  hundred eighty-eight  and  ending  December   thirty-first,   nineteen   hundred eighty-eight,  an  estimate of indirect medical education costs shall be determined in accordance with the methodology applicable for purposes of determining  an  estimate  of  indirect  medical  education  costs   for reimbursement  for inpatient hospital service pursuant to title XVIII of the federal social security act (medicare) in effect on the first day of July in the year preceding the rate period. The council may adopt  rules and  regulations, subject to the approval of the commissioner, to revise the methodology for the determination of an estimate of indirect medical education costs to reflect revisions to the methodology  applicable  for purposes  of  determining  reimbursement  for inpatient hospital service pursuant to title XVIII of the federal social  security  act  (medicare) effective  subsequent to the first day of July in the year preceding the rate period. For annual rate  periods  beginning  on  or  after  January first,  nineteen  hundred  eighty-nine  an  estimate of indirect medical education costs  shall  be  determined  in  accordance  with  rules  and regulations adopted by the council and approved by the commissioner;  (iii)   the   reimbursable   costs   of  schools  of  nursing,  allied professional programs and ambulance services; and  (iv)  the  reimbursable  costs  of  organ  acquisition  services   not reimbursed  pursuant  to  the  methodology  applicable  for  purposes of reimbursement pursuant to title XVIII of the federal social security act (medicare).  (d) The commissioner shall establish, in  accordance  with  rules  and regulations adopted by the council and approved by the commissioner, the methodology to determine the hospital's group category average inpatient reimbursable  operating  cost  per  discharge (price) and the percentage amounts, pursuant to subparagraphs (i), (ii) and (iii) of paragraph  (b) of  subdivision  five  of  this  section,  of the group category average inpatient reimbursable operating  cost  per  discharge  to  be  used  to determine  the  inpatient  reimbursable operating cost component of case based rates for annual rate periods beginning on or after January first, nineteen hundred eighty-eight.   8. Capital related inpatient expenses.  (a) Capital related  inpatient expenses  including  but  not  limited  to straight line depreciation on buildings and non-movable equipment, accelerated depreciation  on  major movable  equipment if requested by the hospital, rentals and interest on capital  debt  (or  for   hospitals   financed   pursuant   to   article twenty-eight-B of this chapter, such expenses, including amortization in lieu  of  depreciation,  as  determined  pursuant  to  the reimbursement  regulations  promulgated  pursuant   to   such   article   and   article twenty-eight  of  this  chapter),  shall be included in rates of payment determined pursuant to this  section  based  on  a  budget  for  capital related   inpatient  expenses  and  subsequently  reconciled  to  actual expenses and statistics through appropriate audit procedures.    General hospitals  shall submit to the commissioner, at least one hundred twenty days prior to the commencement of  each  year,  a  schedule  of  capital related  inpatient  expenses  for  the  forthcoming  year.  Any  capital expenditure which requires or required approval pursuant to this article must have  received  such  approval  for  any  capital  related  expense generated  by  such  capital  expenditure  to  be  included  in rates of payment. The basis for determining capital  related  inpatient  expenses shall  be  the  lesser  of  actual cost or the final amount specifically approved for the construction of the capital asset. The submitted budget may include the capital related  inpatient  expenses  for  all  existing capital  assets  as  well  as  estimates  of  capital  related inpatient expenses for capital assets to be acquired or placed in use prior to the commencement of the rate year or  during  the  rate  year  provided  all required approvals have been obtained.   The  council  shall  adopt,  with  the  approval  of the commissioner, regulations to:  (i) identify by type the eligible capital related inpatient expenses;  (ii) safeguard the future financial viability of voluntary, non-profit general hospitals by requiring  funding  of  inpatient  depreciation  on building and fixed and movable equipment;  (iii)  provide  authorization  to  adjust inpatient rates by advancing payment of depreciation as needed, in instances of capital debt  related financial distress of voluntary, non-profit general hospitals; and  (iv) provide a methodology for the reimbursement treatment of sales.  (b) Capital related inpatient expenses shall be included in case based payments  based  on  the  hospital's  average  capital related inpatient expenses per discharge. Adjustments shall be  made  to  capital  related costs  and  statistics  to  reflect  capital  related inpatient expenses reimbursed on a per diem basis in accordance with paragraphs  (a),  (d), (e), (g) and (i) of subdivision four of this section.  (c)  In order to reconcile capital related inpatient expenses included in rates of payment based on a budget to actual expenses and  statistics for  the  rate  period  for  a  general hospital, rates of payment for a general hospital shall be adjusted to reflect the dollar  value  of  the difference  between  capital  related inpatient expenses included in the computation of rates of payment for a  prior  rate  period  based  on  a budget and actual capital related inpatient expenses for such prior rate period,  each  as  determined  in  accordance with paragraph (a) of this subdivision, adjusted to reflect increases or  decreases  in  volume  of service  in  such  prior  rate  period compared to statistics applied in determining the capital related inpatient expenses component of rates of payment based on  a  budget  for  such  prior  rate  period.  For  rates effective  April  first, two thousand twenty through March thirty-first, two thousand twenty-one, the budgeted capital-related expenses add-on as described in paragraph (a)  of  this  subdivision,  based  on  a  budget submitted  in  accordance to paragraph (a) of this subdivision, shall be reduced by five percent relative to the rate in effect on such date; and the actual capital expenses add-on as described in paragraph (a) of this subdivision, based on actual expenses and statistics through appropriate audit procedures in accordance with paragraph (a)  of  this  subdivision shall  be reduced by five percent relative to the rate in effect on such date. For rates  effective  on  and  after  April  first,  two  thousand twenty-one, the budgeted capital-related expenses add-on as described in  paragraph  (a)  of  this  subdivision,  based  on  a budget submitted in accordance to paragraph (a) of this subdivision, shall be reduced by ten percent relative to the rate in effect on  such  date;  and  the  actual capital   expenses   add-on  as  described  in  paragraph  (a)  of  this subdivision, based on actual expenses and statistics through appropriate audit procedures in accordance with paragraph (a)  of  this  subdivision shall  be  reduced by ten percent relative to the rate in effect on such date. For any rate year, all reconciliation add-on amounts calculated on and after April first, two thousand  twenty  shall  be  reduced  by  ten percent,  and  all  reconciliation  recoupment  amounts calculated on or after April first, two thousand twenty shall increase  by  ten  percent. Notwithstanding  any  inconsistent  provision  of  subparagraph  (i)  of paragraph (e) of subdivision  nine  of  this  section,  capital  related inpatient  expenses of a general hospital included in the computation of rates of payment based  on  a  budget  shall  not  be  included  in  the computation  of  a  volume  adjustment  made  in  accordance  with  such subparagraph. Adjustments to rates of payment  for  a  general  hospital made  pursuant  to  this  paragraph  shall  be  made  in accordance with paragraph (c) of subdivision eleven of this  section.  Such  adjustments shall not be carried forward except for such volume adjustment as may be authorized  in  accordance  with  subparagraph  (i)  of paragraph (e) of subdivision nine of this section for such general hospital.   * (e) Notwithstanding any inconsistent provision of this  subdivision, commencing  April first, nineteen hundred ninety-five, when a factor for reconciliation of budgeted capital related inpatient expenses to  actual capital  related  inpatient expenses for a prior year is included in the capital related inpatient expenses component of rates of  payment,  such capital  related  inpatient expenses component of rates of payment shall be reduced by the commissioner by the difference between the  reconciled capital   related  inpatient  expenses  included  in  rates  of  payment determined in accordance with  paragraphs  (a),  (b)  and  (c)  of  this subdivision  for  such prior year and capital related inpatient expenses for such prior year calculated based on the hospital's  average  capital related inpatient expenses computed on a per diem basis.   * NB Effective through March 31, 2023   * (f)  Notwithstanding  any  inconsistent  provision  of this section, commencing April first, nineteen hundred  ninety-five  for  purposes  of determining the capital related inpatient expenses component of rates of payment  for  patients  eligible for payments made by state governmental agencies for a rate year,  the  submitted  budget  for  capital  related inpatient  expenses  of  a  general hospital applicable to the rate year shall be decreased by the commissioner to reflect the percentage  amount by  which  the budget for the base year two years prior to the rate year for capital related inpatient expenses of the hospital  exceeded  actual expenses.   * NB Effective through March 31, 2023   * (g)  Notwithstanding  any  inconsistent  provision  of this article, commencing April  first,  nineteen  hundred  ninety-five  for  rates  of payment  for  patients  eligible for payments made by state governmental agencies, the capital related inpatient expenses component determined in accordance with paragraph (a) of this subdivision and the  capital  cost per visit components determined in accordance with subparagraphs (i) and (ii) of paragraph (g) of subdivision two of section twenty-eight hundred seven  of  this article shall be adjusted by the commissioner to exclude such expenses related to:  (i) forty-four percent of the costs of major movable equipment; and  (ii) staff housing.   * NB Effective through March 31, 2023    9. Adjustments. For annual rate periods beginning on or after  January first, nineteen hundred eighty-eight:  (a) The commissioner shall on his own initiative, or on the basis of a request from a general hospital, adjust an established rate to reflect:  (i)  the  reduction  of  costs related to the elimination of a general hospital inpatient service in instances where the costs of such  service were included in the rate established; and  (ii) the correction of errors or omissions of data or in computation.  (b)  General hospitals may request and the commissioner shall consider an adjustment to an established rate to reflect  increased  expenses  in excess of costs reported by the general hospital in the nineteen hundred eighty-five  cost  report,  after  application  of  the trend factor, or reconsideration of disallowed expenses based on:  (i) justification of all or a portion of expenses not included in  the rate  resulting from the cost analysis process contained in subparagraph (i) of paragraph (a) of this subdivision;  (ii) additional operational expenses related to approved  construction or service changes;  (iii)  the  addition  of  costs  related  to  a  state requirement for additional services to be provided or additional costs to be incurred in meeting state and federal requirements;  (iv) additional operational expenses to permit a  more  efficient  and economical method of delivering a service;  (v)  increased costs determined to be needed to recruit or maintain an appropriate  level  of  personnel  providing  professional  services  to patients; and  (vi) increased costs for compensation of employees.  (c)   In   determining  the  reasonableness  or  justification  of  an adjustment to an  established  rate  related  to  subparagraph  (vi)  of paragraph (b) of this subdivision, the commissioner shall consider:  (i)  the  fiscal  capability  of  the general hospital to finance such increases from its own resources;  (ii) the  past  history  of  the  general  hospital  with  respect  to compensation increases and allowed compensation trend factors; and  (iii)  the  economy  in  the  area  in  which  the general hospital is located.  (d) General hospitals may request and the commissioner shall  consider a  change  in assignment among the group categories established pursuant to paragraph (b) of subdivision seven  of  this  section  to  which  the hospital  is  assigned  for purposes of computing group category average reimbursable inpatient operating cost per discharge.  (e) (i) Volume adjustments which would result  in  revisions  in  case payment  rates  shall  not  be made to reflect increases or decreases in discharges for other than beneficiaries of title XVIII  of  the  federal social  security  act  (medicare)  in  rate  years beginning on or after January first, nineteen hundred eighty-eight, except in  those  specific instances  where  a  decrease  in  volume  as  measured  by  discharges, including discharges of patients for whom reimbursement is provided on a per diem basis in accordance with paragraph (a) of subdivision eleven of this section, is equal to or greater than one percent of  discharges  in nineteen  hundred  eighty-seven  for  those general hospitals having two hundred or less certified acute care beds  and  classified  as  a  rural hospital  for  purposes  of  determining  payment for inpatient services provided to beneficiaries of title XVIII of the federal social  security act  (medicare) or under state regulations, based on the total number of inpatient acute care beds for which such general hospital  is  certified pursuant  to  the operating certificate issued for such general hospital in accordance with section twenty-eight hundred five of this article  in  effect  on  June  thirtieth,  nineteen  hundred  ninety,  or equal to or greater than ten percent of discharges in nineteen hundred  eighty-seven for all other general hospitals, and the failure to make such adjustment seriously  impacts  on the financial stability of a needed hospital, and except in those specific  instances  where  an  increase  in  volume  as measured  by  discharges  is  equal  to  or  greater than ten percent of discharges in nineteen hundred eighty-seven. Provided, however, that  an adjustment  for  volume  increases  shall  not  apply  to  those general hospitals having two hundred or  less  certified  acute  care  beds  and classified  as  a rural hospital for purposes of determining payment for inpatient services provided to  beneficiaries  of  title  XVIII  of  the federal social security act (medicare) or under state regulations, based on  the total number of inpatient acute care beds for which such general hospital is certified pursuant to the operating certificate  issued  for such  general  hospital  in accordance with section twenty-eight hundred five of this article in  effect  on  June  thirtieth,  nineteen  hundred ninety.  For  general  hospitals and distinct units of general hospitals not reimbursed on a case  based  payment  per  discharge  basis,  volume adjustments  may  be  made  during  the  above  indicated  rate years in accordance with regulations adopted by the council and approved  by  the commissioner.  (ii)  The  commissioner  shall  adjust  the  rates  for  those general hospitals and units of general hospitals excluded from case  payment  in accordance with paragraph (e) or (g) of subdivision four of this section for  case mix changes for other than beneficiaries of title XVIII of the federal social security act (medicare).  (f) General hospitals that did not qualify for a volume adjustment for the nineteen hundred eighty-six and nineteen hundred  eighty-seven  rate periods  for  rates  of  payment  determined  in accordance with section twenty-eight hundred  seven-a  of  this  article  may  request  and  the commissioner  shall  consider an adjustment to an established case based rate of payment for nineteen hundred eighty-eight based on increases  in volume as measured by discharges, based on a comparison between nineteen hundred   eighty-five  and  nineteen  hundred  eighty-seven  discharges, excluding  in  such  comparison   discharges   of   patients   who   are beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare)  and  discharges  related  to  transfer  cases  (transferring hospital) and short stay cases as defined in this section, provided such general  hospital  meets  performance criteria established in accordance with rules and regulations adopted by the council and  approved  by  the commissioner.  Such  criteria  shall include but need not be limited to: maintenance of  like  patient  occupancy  rates  for  the  rate  periods nineteen  hundred  eighty-five, nineteen hundred eighty-six and nineteen hundred eighty-seven; a reduction in patient length of  stay  for  other than  beneficiaries  of  title  XVIII of the federal social security act (medicare) based on a comparison with nineteen hundred eighty-five data; and an expanded use of ambulatory surgery by the general hospital  based on  a comparison with nineteen hundred eighty-five data. Such adjustment shall consider, but need not be limited to, the variable  costs  related to  volume  changes  in accordance with rules and regulations adopted by the council and approved by the commissioner.  (g) All appeals shall be submitted to the commissioner, who may submit a copy of the appeal to interested parties for the purpose of  providing an opportunity for comment within a specified time period.  (h)  The  commissioner  shall act upon all properly documented appeals for adjustments concerning base year costs  by  November  first  of  the calendar  year  for  which  the  rate  is  effective  provided  that all information necessary to determine whether an adjustment is justified is  submitted by the facility prior to May first of such year. In the  event such  an  appeal  is  filed  by  May first, but information necessary to determine whether an adjustment is justified  is  submitted  after  such date,  the  commissioner shall act on the appeal within six months after receiving the necessary information.   * 10. Trend factors. (a) The  commissioner,  in  accordance  with  the methodology  developed  for rate periods through March thirty-first, two thousand, for rates of  payment  for  state  governmental  agencies  and through  December thirty-first, nineteen hundred ninety-six for rates of payment  for  all  other  payors  pursuant  to  paragraph  (b)  of  this subdivision, shall establish trend factors to project for the effects of inflation.  The  factors  shall be applied to the appropriate portion of reimbursable costs. The methodology  for  developing  the  trend  factor shall  include  the appropriate external price indicators and shall also include the data from major collective bargaining agreements as reported quarterly  by  the  federal  department  of  labor,  bureau   of   labor statistics, for non-supervisory employees.  (b)  The methodology shall be developed for rate periods through March thirty-first, two thousand, for rates of payment for state  governmental agencies  and through December thirty-first, nineteen hundred ninety-six for  rates  of  payment  for  all  other  payors  by  four   independent consultants   with   expertise  in  health  economics  or  reimbursement methodologies   for   health-related   services   appointed    by    the commissioner.    For   nineteen   hundred   ninety-six,   through  March thirty-first, two thousand, the commissioner shall  apply  the  nineteen hundred  ninety-five  trend  factor  methodology. The commissioner shall monitor the actual price movements of  the  external   price  indicators used  in the methodology for one interim adjustment to the trend factors to reflect such price movements and one final adjustment  to  the  trend factors  to  reflect  such price movements. At the same time adjustments are made to  the  trend  factors  in  accordance  with  this  paragraph, adjustments  shall be made to all inpatient rates of payment affected by the adjusted trend factors.  (c) (1) For rate periods on and after April first, two  thousand,  the commissioner  shall  establish  trend  factors  for rates of payment for state governmental agencies to project  for  the  effects  of  inflation except  that  such  trend  factors  shall not be applied to services for which rates of payment are  established  by  the  commissioners  of  the department  of  mental  hygiene.  The  factors  shall  be applied to the appropriate portion of reimbursable costs.  (2) In developing  trend  factors  for  such  rates  of  payment,  the commissioner  shall  use  the  most  recent  Congressional Budget Office estimate of the rate year's U.S. Consumer  Price  Index  for  all  urban consumers  published  in  the  Congressional  Budget Office Economic and Budget Outlook after June first of the rate year prior to the  year  for which rates are being developed.  (3)  After  the  final  U.S.  Consumer Price Index (CPI) for all urban consumers is published by the United States Department of Labor,  Bureau of  Labor Statistics, for a particular rate year, the commissioner shall reconcile such final CPI to the projection used in subparagraph  two  of this  paragraph  and  any difference will be included in the prospective trend factor for the current year.  (4) At  the  time  adjustments  are  made  to  the  trend  factors  in accordance  with  this  paragraph,  adjustments  shall  be  made  to all inpatient rates of payment affected by the trend factor adjustment.   * NB Effective until December 31, 2023   * 10. Trend factors. (a) The  commissioner,  in  accordance  with  the methodology  developed  pursuant  to  paragraph (b) of this subdivision,  shall establish trend factors to project for the effects  of  inflation. The  factors shall be applied to the appropriate portion of reimbursable costs. The methodology for developing the trend factor shall include the appropriate  external  price  indicators and shall also include the data from major collective bargaining agreements as reported quarterly by the federal  department  of  labor,  bureau   of   labor   statistics,   for non-supervisory employees.  (b) The methodology shall be developed by four independent consultants with  expertise  in  health economics or reimbursement methodologies for health-related services appointed  by  the  commissioner.  On  or  about September  first  of  each  year,  the  consultants shall provide to the commissioner  and  the  council  a  report  in  writing  detailing   the methodology to be used to determine the trend factors for the subsequent twelve  month  period  commencing  January first. The commissioner shall monitor the actual price movements during this twelve  month  period  of the  external price indicators used in the methodology, shall report the results of the monitoring to the consultants  and  shall  implement  the recommendations  of  the  consultants for one prospective interim annual adjustment to the trend factors to reflect such price movements  and  to be  effective  on January first, one year after the initial trend factor was established and one prospective final annual adjustment to the trend factors to reflect such price movements and to be effective  on  January first,  two years after the initial trend factor was established. At the same time adjustments are made to the trend factors in  accordance  with this  paragraph,  adjustments  shall  be  made to all inpatient rates of payment affected by the adjusted trend factors.   * NB Effective December 31, 2023   11. Special provisions. (a) Notwithstanding any inconsistent provision of this chapter or any other law to the contrary, payment for  inpatient hospital  services  provided on or after January first, nineteen hundred eighty-eight to a patient  admitted  to  a  general  hospital  prior  to January  first,  nineteen  hundred  eighty-eight  otherwise eligible for payment  on  a  case  based  payment   per   discharge   basis   for   a diagnosis-related group shall be at the rate of payment for such general hospital  for such patient in effect for December thirty-first, nineteen hundred  eighty-seven  provided,  however,  that  the   operating   cost components  of  such  rates  of  payment for inpatient hospital services provided on or after January first, nineteen hundred eighty-eight  shall be  projected  to  the  rate  period  by  the trend factor determined in accordance with subdivision ten of this  section  and  reconciled  on  a cumulative  basis  on  or  about  March  thirty-first,  nineteen hundred eighty-eight and December thirty-first,  nineteen  hundred  eighty-eight for  payment  of  adjusted  rates  of payment based on such trend factor adjustment. The  component  of  such  rates  of  payment  based  on  the allowances  provided  in  accordance  with  paragraphs  (e)  and  (f) of subdivision eight  of  section  twenty-eight  hundred  seven-a  of  this article  shall  be  returned  to the applicable regional pool created in accordance with subdivision fifteen of such section and  distributed  in accordance  with  subdivision sixteen of such section based on needs for the financing of losses resulting  from  bad  debts  and  the  costs  of charity care as determined for purposes of nineteen hundred eighty-seven distributions.  (b)  The  council  shall  adopt  rules  and regulations subject to the approval of the commissioner regarding  payor  payment  responsibilities when  a  patient  has  coverage  with  more  than  one payor for general hospital inpatient services and during a hospital stay exhausts benefits available from the primary payor, or receives services not reimbursed by the primary payor, so  that  the  hospital  shall  be  reimbursed  by  a  secondary  payor  for  services not reimbursed by the primary payor that are included as a benefit of the secondary payor. A  primary  payor  for purposes  of this paragraph shall include benefits available pursuant to title XVIII of the federal social security act (medicare).   * (c)(i)  Adjustments  to rates made pursuant to this section for rate periods  commencing  on  or  after  January  first,   nineteen   hundred ninety-seven  may  be  made prospectively or retrospectively on the next following January or July unless otherwise specifically authorized.  (ii) The commissioner may further  adjust  rates  retrospectively  for payments  by state governmental agencies upon a finding that the failure to do so seriously impacts on a general hospital's financial stability.  (iii) Regardless  of  whether  rates  are  adjusted  prospectively  or retrospectively  the  authorized dollar value of the adjustment shall be the same,  calculated  by  including  the  retroactive  impact  of  such adjustment  if  such  adjustment  is  made  prospectively. A prospective adjustment to reflect the retroactive impact of an adjustment  shall  be included in the determination of rates of payment for a prospective rate period  based on the methodology applied in accordance with this section for calculation of rates of payment for such  prospective  rate  period. The  allowance  reflected  in  payments  to a general hospital or a pool related to a  prospective  adjustment  which  reflects  the  retroactive impact  of  an  adjustment  shall  be  computed  based  on the allowance percentage in effect during the prospective period such adjustment is in effect. No recalculation of the basis for distribution of funds from bad debt and charity care  regional  pools  determined  in  accordance  with subdivision  seventeen  of  this section shall be made for a prospective adjustment which reflects the retroactive impact of an adjustment.   * NB Effective until December 31, 2023   * (c)(i) Adjustments to rates made pursuant to this section  shall  be made  prospectively  on  the  next  following  January  or  July  unless otherwise specifically authorized provided, however, that adjustments to rates of payment to  reflect  nineteen  hundred  eighty-seven  data  and statistics   may   be   made   retrospectively  and  such  retrospective adjustments shall, to the  extent  practicable,  be  cumulated  for  one comprehensive adjustment.  (ii)  The commissioner may further adjust rates retrospectively upon a finding that the failure  to  do  so  seriously  impacts  on  a  general hospital's financial stability.  (iii)  Regardless  of  whether  rates  are  adjusted  prospectively or retrospectively the authorized dollar value of the adjustment  shall  be the  same,  calculated  by  including  the  retroactive  impact  of such adjustment if such  adjustment  is  made  prospectively.  A  prospective adjustment  to  reflect the retroactive impact of an adjustment shall be included in the determination of rates of payment for a prospective rate period based on the methodology applied in accordance with this  section for  calculation  of  rates of payment for such prospective rate period, provided, however, that no recalculation of bad debt  and  charity  care allowance percentages determined in accordance with subdivision fourteen of  this  section  shall  be  made  for  a  prospective adjustment which reflects the retroactive impact of  an  adjustment.  The  bad  debt  and charity  care  allowance  of a general hospital related to a prospective adjustment which reflects the retroactive impact of an adjustment  shall be  computed based on the bad debt and charity care allowance percentage of such hospital in effect during the prospective period such adjustment is in effect. No recalculation of the basis for  distribution  of  funds from  bad  debt and charity care regional pools determined in accordance with  subdivision  seventeen  of  this  section  shall  be  made  for  a  prospective  adjustment  which  reflects  the  retroactive  impact of an adjustment.   * NB Effective December 31, 2023  (d)  Working  capital. General hospitals may include as a financing or working capital charge an addition of two percent of any valid claim not paid  within  thirty  days  of  submission  or  determination  of  payor liability,  whichever  is  later,  and one percent per month thereafter. Financing or working capital charges shall not be  applied  to  hospital billings  to  third  party  payors  participating  in an advance payment system. Any payor not participating in  an  advance  payment  system  or offering  admission  billing  shall  allow interim billing for a patient whose stay exceeds thirty days.  (e) (i) Except for payments made pursuant to the workers' compensation law, the volunteer firefighters' benefit law, or the volunteer ambulance workers' benefit law, a  two  percent  discount  from  general  hospital payments  shall be available to all payors whose payments are calculated in accordance with paragraphs (b) and (c) of  subdivision  one  of  this section  making  payment  in  full  to  a  general  hospital for covered hospital services within ten calendar days of receipt from the  hospital by the appropriate payor of a bill for such services.  (ii)  A  three  percentage point reduction in the differential of five percent for general hospital payments shall be available to  all  payors whose  payments  are  calculated  in  accordance  with  paragraph (b) of subdivision one or paragraph (e) of subdivision  four  of  this  section which are making payments pursuant to the workers' compensation law, the volunteer firefighters' benefit law, or the volunteer ambulance workers' benefit  law  when  such payments are made in full to a general hospital for covered hospital services within ninety  calendar  days  of  receipt from  the hospital by the appropriate payor of a bill for such services, and an additional two percentage point reduction shall be available  for such  payors  if such payment is made within forty-five calendar days of receipt of such a bill.  (f) (i) * In order to allow for real  increases  in  general  hospital case  mix  while  limiting the effect of potential case mix changes that are the result of changes in coding practices rather than  real  changes in  case  mix,  the commissioner shall annually for rate periods through December thirty-first, nineteen hundred ninety-six, in  accordance  with rules  and  regulations  adopted  by  the  council  and  approved by the commissioner, adjust individual general hospitals'  case  payment  rates determined  in accordance with paragraphs (a) and (b) of subdivision one of this section to account for increases in the statewide  average  case mix,   based   on   increases   in   statewide   average  assignment  to diagnosis-related groups for all patients other  than  beneficiaries  of title  XVIII  of the federal social security act (medicare), that exceed the allowable statewide increase  determined  in  accordance  with  this subparagraph.  The  commissioner further shall adjust individual general hospitals' case payment rates determined in accordance with this section for state governmental agencies for the periods January first,  nineteen hundred ninety-seven through March thirty-first, two thousand and on and after  April  first, two thousand, in accordance with clause (G) of this subparagraph and to account for increases in statewide average case mix, based on increases in statewide average assignment to  diagnosis-related groups  based  on  data  only for patients that are eligible for medical assistance pursuant to title  eleven  of  article  five  of  the  social services  law,  including  such  patients enrolled in health maintenance organizations, that exceed the allowable statewide  increase  determined in accordance with clause (B-1) of this subparagraph.   * NB Effective until December 31, 2023    * In  order  to  allow for real increases in general hospital case mix while limiting the effect of potential case mix  changes  that  are  the result  of  changes in coding practices rather than real changes in case mix, the commissioner shall annually for rate periods  through  December thirty-first,  nineteen hundred ninety-six, in accordance with rules and regulations adopted by the council and  approved  by  the  commissioner, adjust  individual  general  hospitals' case payment rates determined in accordance with paragraphs (a)  and  (b)  of  subdivision  one  of  this section  to  account  for  increases  in the statewide average case mix, based on increases in statewide average assignment to  diagnosis-related groups  for  all patients other than beneficiaries of title XVIII of the federal social  security  act  (medicare),  that  exceed  the  allowable statewide  increase determined in accordance with this subparagraph. The commissioner further shall adjust  individual  general  hospitals'  case payment  rates  determined  in  accordance  with  this section for state governmental agencies for the periods January  first,  nineteen  hundred ninety-seven through March thirty-first, two thousand in accordance with clause  (G)  of  this  subparagraph  and  to  account  for  increases in statewide average case mix, based  on  increases  in  statewide  average assignment  to  diagnosis-related groups based on data only for patients that are eligible for medical assistance pursuant  to  title  eleven  of article  five  of  the  social  services  law,  including  such patients enrolled in health maintenance organizations, that exceed the  allowable statewide  increase  determined  in accordance with clause (B-1) of this subparagraph.   * NB Effective and expires December 31, 2023   * In order to allow for real increases in general  hospital  case  mix while  limiting  the  effect  of potential case mix changes that are the result of changes in coding practices rather than real changes  in  case mix,  the  commissioner  shall  annually,  in  accordance with rules and regulations adopted by the council and  approved  by  the  commissioner, adjust  individual  general  hospitals' case payment rates determined in accordance with paragraphs (a)  and  (b)  of  subdivision  one  of  this section  to  account  for  increases  in the statewide average case mix, based on increases in statewide average assignment to  diagnosis-related groups  for  all patients other than beneficiaries of title XVIII of the federal social  security  act  (medicare),  that  exceed  the  allowable statewide increase determined in accordance with this subparagraph.   * NB Effective December 31, 2023  (A)  The  increase  in  the  statewide average case mix in a rate year during the period January first, nineteen hundred  eighty-eight  through December  thirty-first,  nineteen hundred ninety-three from the nineteen hundred eighty-seven statewide average case mix  shall  not  exceed  two percent  in  nineteen  hundred eighty-eight compared to nineteen hundred eighty-seven, three percent in nineteen hundred eighty-nine compared  to nineteen  hundred  eighty-seven, four percent in nineteen hundred ninety compared to nineteen hundred  eighty-seven,  five  percent  in  nineteen hundred  ninety-one  compared  to  nineteen  hundred  eighty-seven, and, notwithstanding any  inconsistent  rule  or  regulation,  for  rates  of payment  for state governmental agencies six percent in nineteen hundred ninety-two compared to nineteen hundred eighty-seven and  seven  percent in   nineteen   hundred   ninety-three   compared  to  nineteen  hundred eighty-seven, and for rates of  payment  for  payors  other  than  state governmental  agencies  six and seven-tenths percent in nineteen hundred ninety-two compared to nineteen hundred eighty-seven and  seven  percent in   nineteen   hundred   ninety-three   compared  to  nineteen  hundred eighty-seven.    * (B) The increase in the statewide average case mix in  a  rate  year during  the  period  January first, nineteen hundred ninety-four through December thirty-first, nineteen hundred  ninety-six  from  the  nineteen hundred  ninety-two  statewide average case mix, plus adjustments, shall not  exceed:  for  rates  of payment for state governmental agencies two percent in  the  period  January  first,  nineteen  hundred  ninety-four through    June    thirtieth,   nineteen   hundred   ninety-four,   and, notwithstanding any inconsistent rule or regulation, six and  two-tenths percent  in  the period July first, nineteen hundred ninety-four through December thirty-first, nineteen hundred ninety-four,  three  percent  in the  period  January  first,  nineteen hundred ninety-five through March thirty-first, nineteen hundred ninety-five, two percent  in  the  period April first, nineteen hundred ninety-five through December thirty-first, nineteen  hundred  ninety-five,  and three percent in the period January first,  nineteen  hundred  ninety-six  through  December   thirty-first, nineteen  hundred  ninety-six; and for rates of payment for payors other than  state  governmental  agencies  two  percent  in  nineteen  hundred ninety-four,  three  percent  in  nineteen hundred ninety-five, and four percent in the period January first, nineteen hundred ninety-six through December thirty-first, nineteen hundred ninety-six. Adjustments  to  the nineteen  hundred  ninety-two  statewide  average case mix shall mean an adjustment for any increase in  nineteen  hundred  ninety-two  statewide average  case  mix  compared  to nineteen hundred eighty-seven statewide average  case  mix  in  excess  of  six  percent  of  nineteen   hundred eighty-seven  statewide  average  case  mix  and a further adjustment to reflect that measurement of case mix increase from the nineteen  hundred ninety-two  statewide  average case mix rather than the nineteen hundred eighty-seven  statewide  average  case  mix  reflects  the  increase  in statewide  average  case  mix  from  nineteen  hundred  eighty-seven  to nineteen hundred ninety-two in order to maintain the  effective  maximum rate  of  allowable statewide average case mix increases at a percentage per year of the nineteen hundred  eighty-seven  statewide  average  case mix.  Nineteen  hundred ninety-two case mix shall be determined based on nineteen hundred ninety-two data received by  the  department  by  April thirtieth, nineteen hundred ninety-three.   * NB Effective until December 31, 2023   * (B)  The  increase  in the statewide average case mix in a rate year during the period January first, nineteen  hundred  ninety-four  through June  thirtieth,  nineteen  hundred ninety-six from the nineteen hundred ninety-two statewide average  case  mix,  plus  adjustments,  shall  not exceed: for rates of payment for state governmental agencies two percent in  the  period January first, nineteen hundred ninety-four through June thirtieth,  nineteen  hundred  ninety-four,  and,  notwithstanding   any inconsistent  rule  or  regulation,  six  and  two-tenths percent in the period  July  first,  nineteen  hundred  ninety-four  through   December thirty-first,  nineteen hundred ninety-four, three percent in the period January first, nineteen hundred ninety-five through March  thirty-first, nineteen hundred ninety-five, and two percent in the period April first, nineteen  hundred  ninety-five  through  December thirty-first, nineteen hundred ninety-five, and three percent  in  the  period  January  first, nineteen  hundred  ninety-six  through  June thirtieth, nineteen hundred ninety-six; and for  rates  of  payment  for  payors  other  than  state governmental agencies two percent in nineteen hundred ninety-four, three percent  in nineteen hundred ninety-five, and four percent in the period January first,  nineteen  hundred  ninety-six  through  June  thirtieth, nineteen   hundred  ninety-six.  Adjustments  to  the  nineteen  hundred ninety-two statewide average case mix shall mean an adjustment  for  any increase  in  nineteen  hundred  ninety-two  statewide  average case mix  compared to nineteen hundred eighty-seven statewide average case mix  in excess of six percent of nineteen hundred eighty-seven statewide average case  mix  and  a further adjustment to reflect that measurement of case mix increase from the nineteen hundred ninety-two statewide average case mix rather than the nineteen hundred eighty-seven statewide average case mix  reflects  the  increase in statewide average case mix from nineteen hundred eighty-seven to nineteen hundred ninety-two in order to maintain the effective maximum rate  of  allowable  statewide  average  case  mix increases  at a percentage per year of the nineteen hundred eighty-seven statewide average case mix. Nineteen hundred ninety-two case  mix  shall be  determined based on nineteen hundred ninety-two data received by the department by April thirtieth, nineteen hundred ninety-three.   * NB Effective December 31, 2023  (B-1) The increase in the statewide average case mix  in  the  periods January first, nineteen hundred ninety-seven through March thirty-first, two  thousand  and  on and after April first, two thousand through March thirty-first, two thousand  six  and  on  and  after  April  first,  two thousand  six through March thirty-first, two thousand seven, and on and after April first, two thousand seven through  March  thirty-first,  two thousand  nine,  and on and after April first, two thousand nine through March thirty-first, two thousand eleven, from the statewide average case mix for the period January first, nineteen  hundred  ninety-six  through December  thirty-first, nineteen hundred ninety-six shall not exceed one percent for nineteen hundred  ninety-seven,  two  percent  for  nineteen hundred  ninety-eight,  three  percent  for  the  period  January first, nineteen  hundred  ninety-nine  through  September  thirtieth,  nineteen hundred ninety-nine, four percent for the period October first, nineteen hundred  ninety-nine  through  December  thirty-first,  nineteen hundred ninety-nine, and four percent for two thousand plus  an  additional  one percent  per  year  thereafter,  based  on  comparison  of data only for patients that are eligible for  medical  assistance  pursuant  to  title eleven  of  article  five  of  the  social  services law, including such patients enrolled in health maintenance organizations.  (C) Rate year case mix shall be determined based  on  rate  year  data received  by the department by April thirtieth next following the end of the rate year. Case mix may be determined based on general hospital data received or amended after such  due  dates  provided,  however,  that  a general  hospital  that does not submit the appropriate data in a timely manner shall be subject to the provisions of section  twelve-d  of  this chapter.   * (D) If in any rate period on an annualized basis the cumulative case mix  increase exceeds the allowable statewide increase, rates of payment to general hospitals shall be adjusted  in  accordance  with  rules  and regulations  adopted  by  the  council  and approved by the commissioner which shall contain the specific methodology to allocate  the  reduction among  general hospitals, in order to reduce the effect of the statewide increase  on  rates  of  payment  to  reflect  the  allowable  increase. Notwithstanding  any  inconsistent  provision  of  this  paragraph, rate adjustments for purposes of this paragraph shall be made on a six  month rate   period   basis  for  the  period  July  first,  nineteen  hundred ninety-four through December thirty-first, nineteen hundred ninety-four. The retroactive impact of adjustments to rates  of  payment  for  payors other  than  state governmental agencies based on the amendments to this paragraph effective July first, nineteen hundred  ninety-four  shall  be reflected  in  a  prospective  adjustment  to  rates of payment for such payors for the period July first, nineteen hundred  ninety-four  through December thirty-first, nineteen hundred ninety-four.   * NB Effective until December 31, 2023    * (D) If in any rate year the cumulative case mix increase exceeds the allowable  statewide  increase,  rates  of  payment to general hospitals shall be adjusted in accordance with rules and  regulations  adopted  by the  council  and  approved  by the commissioner which shall contain the specific  methodology to allocate the reduction among general hospitals, in order to reduce the effect of the  statewide  increase  on  rates  of payment   to   reflect   the  allowable  increase.  Notwithstanding  any inconsistent provision of this paragraph, rate adjustments for  purposes of this paragraph shall be made on a six month rate period basis for the period   July  first,  nineteen  hundred  ninety-four  through  December thirty-first, nineteen hundred ninety-four. The  retroactive  impact  of adjustments to rates of payment for payors other than state governmental agencies based on the amendments to this paragraph effective July first, nineteen  hundred  ninety-four  shall  be  reflected  in  a  prospective adjustment to rates of payment for  such  payors  for  the  period  July first,  nineteen  hundred  ninety-four  through  December  thirty-first, nineteen hundred ninety-four.   * NB Effective December 31, 2023  (E) Such methodology shall take into account past trends of individual general hospitals' case mix changes, and, within the aggregate allowable statewide increase in case mix, permit general hospitals  to  appeal  to the  commissioner  their  proposed allocation of a reduction in rates of payment related to increases in statewide average case mix based on such factors as changes in hospital service delivery and referral patterns.  (F) Case mix changes  due  to  acquired  immune  deficiency  syndrome, tuberculosis, epidemics or other catastrophes resulting in extraordinary hospital utilization shall not be subject to this limitation.   * (G)  Adjustments  determined  in  accordance with clause (B) of this subparagraph for the period January first, nineteen  hundred  ninety-six through  December  thirty-first,  nineteen hundred ninety-six on a final basis, and in accordance with subparagraph (ii) of this paragraph on  an interim   basis,  shall  be  applied  to  rates  of  payment  for  state governmental agencies during the period January first, nineteen  hundred ninety-seven through March thirty-first, two thousand and periods on and after April first, two thousand.   * NB Expires December 31, 2023   * (G)  Adjustments  determined  in  accordance with clause (B) of this subparagraph for the period  January first, nineteen hundred  ninety-six through  December  thirty-first,  nineteen hundred ninety-six on a final basis, and in accordance with subparagraph (ii) of this paragraph on  an interim   basis,  shall  be  applied  to  rates  of  payment  for  state governmental agencies during the period January first, nineteen  hundred ninety-seven through March thirty-first, two thousand.   * NB Effective and repealed December 31, 2023   * (ii)  (A)  The  commissioner  shall,  in  accordance  with rules and regulations adopted by the council and approved by the commissioner, for purposes of  payments  on  an  interim  basis  periodically  compute  an adjustment to individual general hospitals' case payment rates for prior periods  for the payor categories specified in paragraphs (a) and (b) of subdivision one  of  this  section  to  account  for  increases  in  the statewide  average  case  mix,  based  on increases in statewide average assignment to diagnosis-related  groups  for  all  patients  other  than beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare), that exceed the allowable statewide increase.  The  increase in  the  statewide  average  case  mix  in a rate year during the period January  first,   nineteen   hundred   eighty-eight   through   December thirty-first,  nineteen  hundred  ninety-three from the nineteen hundred eighty-seven statewide average case mix and in a rate  year  during  the  period  January  first,  nineteen  hundred  ninety-four through December thirty-first, nineteen hundred ninety-six  from  the  adjusted  nineteen hundred  ninety-two  statewide  average  case  mix  shall not exceed the allowable   statewide   increase   as   determined  in  accordance  with subparagraph (i) of  this  paragraph.  Adjustments  may  be  made  on  a quarterly  basis  consistent  with  this  annual  limitation.  If in any quarter of the rate year the cumulative case mix increase for  the  rate year  exceeds the allowable statewide increase, payment rates to general hospitals shall be adjusted in accordance  with  rules  and  regulations adopted  by  the  council  and  approved by the commissioner which shall contain the specific methodology to allocate the reduction among general hospitals provided,  however,  that  any  funds  to  be  recovered  from hospitals based on such adjustments for prior periods shall be recovered by  prospective  adjustment  of  rates  of  payment  in  accordance with paragraph (c) of this subdivision, in order to reduce the effect of  the statewide  increase  on  rates  of  payment  to  reflect  the  allowable increase,  taking  into  consideration  the  effect  of  any  adjustment applicable in the rate period made in accordance with subparagraph (iii) of  this  paragraph.  Case mix changes due to acquired immune deficiency syndrome, tuberculosis, epidemics or  other  catastrophes  resulting  in extraordinary   hospital  utilization  shall  not  be  subject  to  this limitation, pursuant to rules and regulations adopted by the council and approved by the commissioner.  (B) The commissioner further shall for  purposes  of  payments  on  an interim  basis  periodically compute an adjustment to individual general hospitals' case payment rates for prior periods  for  payments  made  by state  governmental  agencies  to account for increases in the statewide average case mix, based on increases in statewide average assignment  to diagnosis-related  groups  for  patients  that  are eligible for medical assistance pursuant to title  eleven  of  article  five  of  the  social services  law  eligible for payments made by state governmental agencies or by  health  maintenance  organizations,  that  exceed  the  allowable statewide  increase  as  determined  in  accordance with clause (B-1) of subparagraph (i) of this paragraph.   * NB Effective until December 31, 2023   * (ii)  The  commissioner  shall,  in  accordance   with   rules   and regulations adopted by the council and approved by the commissioner, for purposes  of  payments  on  an  interim  basis  periodically  compute an adjustment to individual general hospitals' case payment rates for prior periods for the payor categories specified in paragraphs (a) and (b)  of subdivision  one  of  this  section  to  account  for  increases  in the statewide average case mix, based  on  increases  in  statewide  average assignment  to  diagnosis-related  groups  for  all  patients other than beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare),  that  exceed the allowable statewide increase. The increase in the statewide average case mix in  a  rate  year  during  the  period January   first,   nineteen   hundred   eighty-eight   through  December thirty-first, nineteen hundred ninety-three from  the  nineteen  hundred eighty-seven  statewide  average  case mix and in a rate year during the period  January  first,  nineteen  hundred  ninety-four   through   June thirtieth,  nineteen  hundred  ninety-six  from  the  adjusted  nineteen hundred ninety-two statewide average  case  mix  shall  not  exceed  the allowable   statewide   increase   as   determined  in  accordance  with subparagraph (i) of  this  paragraph.  Adjustments  may  be  made  on  a quarterly  basis  consistent  with  this  annual  limitation.  If in any quarter of the rate year the cumulative case mix increase for  the  rate year  exceeds the allowable statewide increase, payment rates to general hospitals shall be adjusted in accordance  with  rules  and  regulations  adopted  by  the  council  and  approved by the commissioner which shall contain the specific methodology to allocate the reduction among general hospitals provided,  however,  that  any  funds  to  be  recovered  from hospitals based on such adjustments for prior periods shall be recovered by  prospective  adjustment  of  rates  of  payment  in  accordance with paragraph (c) of this subdivision, in order to reduce the effect of  the statewide  increase  on  rates  of  payment  to  reflect  the  allowable increase,  taking  into  consideration  the  effect  of  any  adjustment applicable in the rate period made in accordance with subparagraph (iii) of  this  paragraph.  Case mix changes due to acquired immune deficiency syndrome, tuberculosis, epidemics or  other  catastrophes  resulting  in extraordinary   hospital  utilization  shall  not  be  subject  to  this limitation, pursuant to rules and regulations adopted by the council and approved by the commissioner.   * NB Effective December 31, 2023  (iii) The commissioner shall, in accordance with rules and regulations adopted by the council and approved by  the  commissioner,  periodically prospectively  adjust  for  purposes  of  payments  on  an interim basis individual  general  hospitals'  case  payment  rates  for   the   payor categories  specified  in  paragraphs  (a) and (b) of subdivision one of this section to account for increases in statewide average assignment to diagnosis-related groups which exceed the allowable  statewide  increase as determined in accordance with subparagraph (ii) of this paragraph.  (iv)  Rates  of  payment  of  a  general hospital shall be adjusted in accordance with  paragraph  (c)  of  this  subdivision  to  reflect  the difference  between  an individual general hospital's case payment rates adjusted in accordance with subparagraph (i) of  this  paragraph  for  a rate  period and such rates determined in accordance with paragraphs (a) and (b) of subdivision one of this section,  taking  into  consideration any  adjustment  to  case  payment rates applicable for such rate period made in accordance with subparagraphs (ii) and (iii) and for the periods beginning on or after July first, nineteen hundred ninety,  subparagraph (v) of this paragraph.  (v) Notwithstanding any inconsistent provision of law, for the periods beginning on or after July first, nineteen hundred ninety and subsequent annual  rate  periods  beginning  January  first  the commissioner shall reduce, in accordance with  the  methodology  adopted  for  purposes  of adjustments  pursuant  to  subparagraph  (ii)  of  this  paragraph,  for purposes of payments on an interim basis individual  general  hospitals' case  payment  rates  applicable  to  state  governmental agencies for a prospective period to reflect an estimate of the cumulative increase  in statewide  average  assignment  to  diagnosis-related  groups  for prior periods including prior quarters of the rate period  which  exceeds  the allowable  statewide  increase  specified  in  subparagraph  (i) of this paragraph for the prospective period. Such adjustment  if  effected  for less  than an annual prospective rate period shall reflect an annualized adjustment.  (vi) Notwithstanding any inconsistent provision of law, adjustments to rates of payment pursuant to this paragraph based  on  nineteen  hundred ninety-three  data  that  reflects an increase in statewide average case mix compared to nineteen hundred eighty-seven that exceeds the  increase based  on nineteen hundred ninety-two data in statewide average case mix compared to nineteen hundred eighty-seven shall not be implemented until April  first,  nineteen  hundred   ninety-five   and   shall   be   made prospectively  for  rates  of  payment  issued  effective  April  first, nineteen hundred ninety-five including the impact of such adjustment for the period January first, nineteen  hundred  ninety-five  through  March thirtieth, nineteen hundred ninety-five.  (g)  Notwithstanding  any  other provisions of this section, all costs and statistics that  are  related  to  inpatient  services  provided  to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare) shall not be included in the  establishment  of  any  payment rates computed in accordance with the provisions of this section.  (i)  Unless provided otherwise in specific provisions included in this section, the exclusion of costs which are related to  routine  inpatient services  provided to beneficiaries of title XVIII of the federal social security act (medicare) and covered by title XVIII of the federal social security  act  (medicare)  shall  be  based  on  the  nineteen   hundred eighty-five  inpatient  days actually paid on behalf of beneficiaries of title XVIII of the federal social security act (medicare) plus any  days for  such  beneficiaries not paid on the basis of a decision by a review agent that  the  days  were  unnecessary.  Ancillary  costs  related  to inpatient  services  provided  to  beneficiaries  of  title XVIII of the federal social security act (medicare) and covered by title XVIII of the federal social security act (medicare) shall be excluded on the basis of the nineteen hundred eighty-five cost center ratio of hospital ancillary inpatient  service  charges  related  to  such  beneficiaries  to  total hospital  cost  center  inpatient  ancillary services charges applied to cost center costs.  Inpatient  malpractice  insurance  costs  which  are attributable   to  title  XVIII  of  the  federal  social  security  act (medicare) shall be excluded based on the methodology employed by  title XVIII  of  the  federal  social security act (medicare) to identify such costs.  (ii) Costs and statistics related to inpatient  services  provided  to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare) and covered  by  a  secondary  payor  shall  be  excluded  in accordance  with  rules  and  regulations  adopted  by  the  council and approved by the commissioner in the determination of case payment  rates computed in accordance with the provisions of this section.  (h)(i) Any malpractice insurance costs which are the result of general hospitals  having  to  purchase  or provide excess malpractice insurance coverage for physicians in accordance with section nineteen  of  chapter two  hundred  ninety-four of the laws of nineteen hundred eighty-five or section eighteen of  chapter  two  hundred  sixty-six  of  the  laws  of nineteen  hundred  eighty-six  as  amended  shall  not  be  included  in calculating malpractice insurance costs for purposes of paragraph (e) of subdivision one of this section.  (ii)  The  component  of  general  hospital   reimbursable   inpatient operating  costs  based  on the general hospital's inpatient malpractice insurance costs plus  the  component  of  special  additional  inpatient operating  costs  determined  in  accordance  with subparagraphs (i) and (iii) of paragraph (e) of subdivision one of this  section  specifically related  to  inpatient  malpractice  insurance  costs  used to determine payment rates for annual rate periods  beginning  on  or  after  January first, nineteen hundred eighty-eight shall be allocated among the payors in  accordance  with  regulations adopted by the council and approved by the commissioner.  (i) For patients discharged during the period  April  first,  nineteen hundred   ninety-two   through   March  thirty-first,  nineteen  hundred ninety-three insured under a commercial insurer licensed to do  business in  this state and authorized to write accident and health insurance and whose policy provides inpatient hospital coverage on an expense incurred basis, the payment rate shall be increased in addition  to  the  payment rate  conversion  factor  of thirteen percent by a supplementary payment rate conversion factor of eleven percent for a total  conversion  factor of  twenty-four  percent.  This  paragraph  shall  not apply to payments  pursuant to the workers' compensation law, the  volunteer  firefighters' benefit   law,   the  volunteer  ambulance  workers'  benefit  law,  the comprehensive motor vehicle insurance reparations act, the terms of  any personal  injury  liability  insurance  policy, marine and inland marine insurance policy or marine protections and indemnity insurance policy.  (j) No operating cost  ceilings  or  disallowances  other  than  those applicable  for  purposes  of  the determination of a general hospital's reimbursable inpatient operating cost base in accordance with  paragraph (d)  of  subdivision  one  of  this  section shall be applied to general hospitals, except for any cost ceilings  or  disallowances  applied  for purposes   of   subdivision   twenty-four   of  this  section  and  cost disallowances for general hospitals with rates based on budgeted costs.  (k) Notwithstanding any inconsistent provision of this  section,  case based  rates  of payment per discharge may, in accordance with rules and regulations adopted by the council and  approved  by  the  commissioner, reflect  incorporation  of  severity  of  illness  considerations in the methodology to determine such rates of payment.  (l)  Notwithstanding  any  inconsistent  provision  of  this  section, nothing  in  this  section  shall  preclude a modification to case based rates of payment per discharge in accordance with rules and  regulations adopted  by  the  council  and  approved  by the commissioner to reflect readmission of an individual or unnecessary multiple  admissions  of  an individual to a general hospital or general hospitals.  (m)  Notwithstanding  any  inconsistent  provision  of this section, a general hospital that exceeded maximum charge limitations as  determined by  the  commissioner  in  the rate periods nineteen hundred eighty-four through nineteen hundred eighty-seven may be  authorized  in  accordance with  rules  and  regulations adopted by the council and approved by the commissioner to reduce payments determined pursuant to this  section  in order  to  effect  a  reduction  equivalent to such amount by which such general hospital exceeded maximum charge limitations.  (n) (i) For a patient discharged from a general hospital on  or  after August  first,  nineteen  hundred  eighty-eight  and  covered by a payor included in the payor categories specified in paragraph (a)  or  (b)  of subdivision   one  of  this  section  that  provides  for  a  percentage coinsurance responsibility by or on behalf of such patient  for  covered hospital  services:  (A) the dollar value of such percentage coinsurance responsibility by or on behalf of such patient shall  be  determined  by multiplying  such  coinsurance  percentage by the hospital's charges for such patient, determined in accordance with paragraph (c) of subdivision one of this section or paragraph (e) of subdivision four of this section for a general hospital or  distinct  unit  of  a  general  hospital  not reimbursed  on  case  based  payments,  for  the services covered by the payor, considering any applicable deductibles, and (B) the  payment  due to  a  general hospital for reimbursement of inpatient hospital services by such payor shall  be  determined  by  multiplying  the  payment  rate determined  in accordance with this section for such patient for covered hospital services by the coinsurance percentage for which such payor  is responsible, considering any applicable deductibles.  (ii)  A  patient  covered  by a payor included in the payor categories specified in paragraph (a) or (b) of subdivision  one  of  this  section shall  be  deemed  liable  for  the  payment rate for inpatient hospital services for such patient for covered services determined in  accordance with this section based on the rate of payment for such payor, provided, however,  that  for  a  patient discharged from a general hospital on or after  August  first,  nineteen  hundred   eighty-eight   a   percentage coinsurance  responsibility  by  or  on  behalf of such patient shall be deemed satisfied by payment of  the  dollar  value  of  such  percentage  coinsurance  responsibility  determined in accordance with clause (A) of subparagraph (i) of this paragraph.  (o) No general hospital shall refuse to provide hospital services to a person  presented  or  proposed  to  be  presented for admission to such general hospital by a representative of a  correctional  facility  or  a local  correctional  facility  as  defined  respectively in subdivisions four, fifteen and sixteen of section two of  the  correction  law  based solely  on the grounds such person is an incarcerated individual of such correctional  facility  or  local  correctional  facility.  No   general hospital may demand or request any charge for hospital services provided to  such  person  in  addition  to  the  charges  or rates authorized in accordance with  this  article,  except  for  charges  for  identifiable additional  hospital  costs  associated  with  or  reasonable additional charges associated with security arrangements for such person.  (p)(i) Notwithstanding any inconsistent provision of  law,  a  general hospital  that  provides  an  inpatient  component  of  hospice care for persons eligible for payments to a hospice by a government  agency  made in  accordance  with subdivisions two and three of section four thousand twelve of this chapter shall be reimbursed for such  inpatient  services by  or on behalf of the hospice at a rate of payment no greater than the applicable rate of payment determined in  accordance  with  subdivisions two  and  three of section four thousand twelve of this chapter for such hospice and no general hospital may charge for such  inpatient  services rendered an amount in excess of such applicable rate of payment.  (ii)  Notwithstanding  any  inconsistent  provision  of law, a general hospital that  provides  in  accordance  with  contractual  arrangements between  a  hospice  and such general hospital an inpatient component of hospice care for persons who  are  not  eligible  for  payments  to  the hospice  by a government agency made in accordance with subdivisions two and three of  section  four  thousand  twelve  of  this  chapter  or  as beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare) shall be reimbursed for such  inpatient  services  by  or  on behalf of the hospice in accordance with such contractual arrangements.  (q)  A  third-party  payor  specified  in paragraph (a), (b) or (c) of subdivision one of this section,  with  the  exception  of  governmental agencies, shall provide the general hospital with a remittance advice at the  time payment or adjustment to such payment is made. Such remittance advice shall include the patient's name, date of service,  admission  or financial  control  number  if  available  and  diagnosis-related  group classification number if applicable and if different than that billed by the hospital. Such remittance advice shall also include (i)  the  amount or percentage payable under the policy or certificate after deductibles, co-payments  and  any  other  reduction  of  the amount billed including deductions for prompt payment; and (ii) a specific  explanation  of  any denial, reduction, or other reason including any other third-party payor coverage, for not providing full reimbursement of the amount claimed.   * (r)  Notwithstanding any inconsistent provision of this section, for purposes of establishing rates of payment by state governmental agencies for general hospital inpatient services provided for  discharges  on  or after  April  first, nineteen hundred ninety-five, the reimbursable base year inpatient administrative and general costs of a  general  hospital, which  shall  include  but not be limited to reported administrative and general, data processing, non-patient telephone, purchasing,  admitting, and  credit  and collection costs, excluding a provider reimbursed on an initial budget basis, shall not exceed the statewide  average  of  total reimbursable  base  year inpatient administrative and general costs. For the purposes of this paragraph, reimbursable  base  year  administrative and  general costs shall mean those base year administrative and general  costs remaining after application of  all  other  efficiency  standards, including,  but  not limited to, peer group cost ceilings or guidelines. The limitation on reimbursement for provider administrative and  general expenses  provided  by this paragraph shall be expressed as a percentage reduction of the operating cost component of the rate promulgated by the commissioner for each general hospital.   * NB Expired March 31, 2011   * (s) Notwithstanding any inconsistent provisions of this section, for the  period  July  first,  nineteen  hundred  ninety-six  through  March thirty-first,  nineteen  hundred  ninety-seven,  the  commissioner shall increase rates of payment for patients eligible  for  payments  made  by state  governmental  agencies  by  an  amount  not  to exceed forty-five million dollars in the aggregate to be allocated among  those  voluntary non-profit and private proprietary general hospitals which qualified for rate  adjustments pursuant to this paragraph as in effect for the period July  first,  nineteen  hundred  ninety-five  through  June   thirtieth, nineteen  hundred  ninety-six  proportionally based on each such general hospital's proportional share of the total funds allocated  pursuant  to this  paragraph  as  in  effect  for  the period of July first, nineteen hundred ninety-five through June thirtieth, nineteen hundred ninety-six.   * NB Expires December 31, 2023  (s-1) To the extent funds are available pursuant to the provisions  of paragraph  (s-2)  of  this subdivision and otherwise notwithstanding any inconsistent provision of law to the  contrary,  for  the  rate  periods September   first,   nineteen   hundred   ninety-seven   through   March thirty-first, nineteen hundred ninety-eight, and April  first,  nineteen hundred   ninety-eight  through  March  thirty-first,  nineteen  hundred ninety-nine, the  commissioner  shall  increase  rates  of  payment  for patients eligible for payments made by state governmental agencies by an amount  not  to  exceed forty-eight million dollars in the aggregate for each such rate period, allocated among those  voluntary  non-profit  and private   proprietary   general   hospitals  which  qualified  for  rate adjustments pursuant to paragraph (s) of this subdivision as  in  effect for  the  period  July  first, nineteen hundred ninety-five through June thirtieth, nineteen hundred ninety-six proportionally based on each such general hospital's proportional share of total funds allocated  pursuant to paragraph (s) of this subdivision as in effect for the period of July first,  nineteen  hundred  ninety-five  through June thirtieth, nineteen hundred ninety-six. The rate adjustments calculated in  accordance  with this  paragraph  shall  be  subject  to  retrospective reconciliation to ensure that each hospital receives in the  aggregate  its  proportionate share of the full allocation, to the extent allowable under federal law, provided  however that the department shall not be required to reconcile payments made pursuant to paragraph (s) of this  subdivision  applicable to periods prior to September first, nineteen hundred ninety-seven.  (s-2)  (i)  Notwithstanding  any  inconsistent provision of law to the contrary, the following  funds  heretofore  or  hereinafter  accumulated shall  be  transferred by the commissioner and credited to the credit of the state general fund medical assistance local assistance account in an aggregate amount equal to the non-federal share of the costs of the rate adjustments authorized pursuant to paragraph (s-1) of this subdivision:  (A) from pool reserves from statewide and regional  pools  established pursuant  to sections twenty-eight hundred seven-a, twenty-eight hundred seven-c, and twenty-eight hundred eight-c of this article;  (B) from unobligated monies available pursuant  to  paragraph  (b)  of subdivision  nineteen  of  section  twenty-eight hundred seven-c of this article;  (C) from interest income derived from pools  established  pursuant  to sections  twenty-eight hundred seven-k, twenty-eight hundred seven-l and twenty-eight hundred seven-s of this article.  (ii)  To the extent that funds available pursuant to the provisions of subparagraph  (i)  of  this  paragraph  are  insufficient  to  meet  the non-federal  share  of  the  costs  of  the  rate adjustments authorized pursuant to paragraph (s-1) of this  subdivision,  the  following  funds hereto or hereinafter accumulated may be transferred by the commissioner to  the  state  general fund medical assistance local assistance account for the purposes set forth in subparagraph (i) of this paragraph:  (A) from unobligated monies available pursuant to paragraphs  (g)  and (j)  of  subdivision  1  of section twenty-eight hundred seven-l of this article;  (B) from unobligated  monies  available  pursuant  to  clause  (D)  of subparagraph  (ii)  of  paragraph  (b)  of  subdivision  one  of section twenty-eight hundred seven-l of this article.  (iii)  Notwithstanding  any  inconsistent  provision  of  law  to  the contrary,  the  commissioner  shall  transfer  up  to  an additional two million dollars from the funding sources identified in subparagraph  (i) of  this  paragraph  to  the  state  general  fund. To the extent monies available from the funding sources identified  in  subparagraph  (i)  of this  paragraph  total  less  than two million dollars, the commissioner shall transfer monies from funding sources  identified  in  subparagraph (ii)  of  this  paragraph  to  the  state general fund so that the total amount  transferred  pursuant  to  this  provision  equals  two  million dollars.  (s-3)  To the extent funds are available pursuant to the provisions of paragraph (s-4) of this subdivision and  otherwise  notwithstanding  any inconsistent  provision of law to the contrary, for the rate period July first, nineteen hundred  ninety-nine  through  March  thirty-first,  two thousand,  the commissioner shall increase rates of payment for patients eligible for payments made by state governmental agencies by  an  amount not  to  exceed thirty-six million dollars in the aggregate. Such amount shall  be  allocated  among  those  voluntary  non-profit  and   private proprietary  general  hospitals  which  continue  to  provide  inpatient services as of July first, nineteen hundred ninety-nine under a previous or new name  and  which  qualified  for  rate  adjustments  pursuant  to paragraph  (s)  of  this  subdivision  as  in effect for the period July first, nineteen hundred ninety-five  through  June  thirtieth,  nineteen hundred  ninety-six proportionally based on each such general hospital's proportional share of total funds allocated pursuant to paragraph (s) of this subdivision as in effect for the period  of  July  first,  nineteen hundred ninety-five through June thirtieth, nineteen hundred ninety-six, provided  however,  that  amounts  allocable to previously but no longer qualified hospitals shall be proportionally reallocated to the remaining qualified hospitals. The rate adjustments calculated in accordance  with this  paragraph  shall  be  subject  to  retrospective reconciliation to ensure that each hospital receives in the  aggregate  its  proportionate share of the full allocation, to the extent allowable under federal law, provided  however that the department shall not be required to reconcile payments made pursuant to paragraph (s) of this  subdivision  applicable to periods prior to September first, nineteen hundred ninety-seven.  (s-4)  Notwithstanding  any  inconsistent  provision  of  law  to  the contrary, funds available pursuant to section 32-c  of  part  F  of  the chapter  of  the  laws  of  nineteen hundred ninety-nine which adds this paragraph shall be transferred by the commissioner and credited  to  the credit  of  the  state  general fund medical assistance local assistance account in an aggregate amount equal to the  non-federal  share  of  the  costs  of the rate adjustments authorized pursuant to paragraph (s-3) of this subdivision.   * (s-5) To the extent funds are available pursuant to paragraph (s) of subdivision  one of section twenty-eight hundred seven-v of this article and otherwise notwithstanding any inconsistent  provision  of  law,  for rate  periods  April first, two thousand through March thirty-first, two thousand three, the commissioner shall increase  rates  of  payment  for patients eligible for payments made by state governmental agencies by an amount  not  to  exceed  forty-eight  million  dollars  annually  in the aggregate.  Such  amount  shall  be  allocated  among  those   voluntary non-profit  and  private proprietary general hospitals which continue to provide  inpatient  services  as  of  July   first,   nineteen   hundred ninety-nine  under  a  previous or new name and which qualified for rate adjustments pursuant to paragraph (s) of this subdivision as  in  effect for  the  period  July  first, nineteen hundred ninety-five through June thirtieth, nineteen hundred ninety-six proportionally based on each such general hospital's proportional share of total funds allocated  pursuant to paragraph (s) of this subdivision as in effect for the period of July first,  nineteen  hundred  ninety-five  through June thirtieth, nineteen hundred  ninety-six,  provided  however,  that  amounts   allocable   to previously  but  no  longer  qualified hospitals shall be proportionally reallocated to the remaining qualified hospitals. The  rate  adjustments calculated  in  accordance  with  this  paragraph  shall  be  subject to retrospective reconciliation to ensure that each  hospital  receives  in the  aggregate  its  proportionate  share of the full allocation, to the extent allowable under federal law, provided however that the department shall not be required to reconcile payments made pursuant  to  paragraph (s)  of this subdivision applicable to periods prior to September first, nineteen hundred ninety-seven.   * NB Expires December 31, 2023  (s-6) To the extent funds are available otherwise notwithstanding  any inconsistent  provision  of  law to the contrary, for rate periods April first, two thousand three through March thirty-first, two thousand five, the commissioner shall increase rates of payment for  patients  eligible for  payments  made  by  state governmental agencies by an amount not to exceed forty-eight million  dollars  annually  in  the  aggregate.  Such amount  shall  be allocated among those voluntary non-profit and private proprietary  general  hospitals  which  continue  to  provide  inpatient services as of July first, nineteen hundred ninety-nine under a previous or  new  name  and  which  qualified  for  rate  adjustments pursuant to paragraph (s) of this subdivision as  in  effect  for  the  period  July first,  nineteen  hundred  ninety-five  through June thirtieth, nineteen hundred ninety-six proportionally based on each such general  hospital's proportional share of total funds allocated pursuant to paragraph (s) of this  subdivision  as  in  effect for the period of July first, nineteen hundred ninety-five through June thirtieth, nineteen hundred ninety-six, provided however, that amounts allocable to  previously  but  no  longer qualified hospitals shall be proportionally reallocated to the remaining qualified  hospitals. The rate adjustments calculated in accordance with this paragraph shall  be  subject  to  retrospective  reconciliation  to ensure  that  each  hospital receives in the aggregate its proportionate share of the full allocation, to the extent allowable under federal law, provided however that the department shall not be required to  reconcile payments  made  pursuant to paragraph (s) of this subdivision applicable to periods prior to  September  first,  nineteen  hundred  ninety-seven. These  payments  may  be  added to rates of payment or made as aggregate payments to eligible hospitals.  (s-7) To the extent funds are available otherwise notwithstanding  any inconsistent  provision  of  law to the contrary, for rate periods April first, two thousand five through March thirty-first, two thousand seven, the commissioner shall increase rates of payment for  patients  eligible for  payments  made  by  state governmental agencies by an amount not to exceed forty-eight million  dollars  annually  in  the  aggregate.  Such amount  shall  be allocated among those voluntary non-profit and private proprietary  general  hospitals  which  continue  to  provide  inpatient services  as  of  April first, two thousand five under a previous or new name and which qualified for rate adjustments pursuant to paragraph  (s) of  this  subdivision  as  in effect for the period July first, nineteen hundred ninety-five through June thirtieth, nineteen hundred  ninety-six proportionally  based on each such general hospital's proportional share of total funds allocated pursuant to paragraph (s) of  this  subdivision as  in effect for the period of July first, nineteen hundred ninety-five through June thirtieth, nineteen hundred ninety-six,  provided  however, that  amounts  allocable to previously but no longer qualified hospitals shall  be  proportionally  reallocated  to   the   remaining   qualified hospitals.  The  rate  adjustments  calculated  in  accordance with this paragraph shall be subject to  retrospective  reconciliation  to  ensure that  each hospital receives in the aggregate its proportionate share of the full allocation, to the extent allowable under federal law, provided however that the department shall not be required to reconcile  payments made pursuant to paragraph (s) of this subdivision applicable to periods prior to September first, nineteen hundred ninety-seven.  (s-8)  To the extent funds are available and otherwise notwithstanding any inconsistent provision of law to the contrary, for rate  periods  on and  after  April  first, two thousand seven through November thirtieth, two thousand nine, the commissioner shall increase rates of payment  for patients eligible for payments made by state governmental agencies by an amount  not  to  exceed sixty million dollars annually in the aggregate. Such amount shall be allocated among those voluntary non-profit  general hospitals  which  continue  to  provide  inpatient  services as of April first, two thousand seven through March thirty-first, two thousand eight and which have medicaid inpatient discharges  percentages  equal  to  or greater  than  thirty-five  percent.  This  percentage shall be computed based upon data reported  to  the  department  in  each  hospital's  two thousand  four institutional cost report, as submitted to the department on or before January first, two thousand  seven.  The  rate  adjustments calculated   in  accordance  with  this  paragraph  shall  be  allocated proportionally based on each eligible hospital's total reported medicaid inpatient discharges  in  two  thousand  four,  to  the  total  reported medicaid  inpatient  discharges  for  all such eligible hospitals in two thousand four, provided, however, that such rate  adjustments  shall  be subject  to  reconciliation to ensure that each hospital receives in the aggregate its proportionate share of the full allocation to  the  extent allowable  under  federal  law.  Such  payments may be added to rates of payment or made as aggregate payments to eligible  hospitals,  provided, however,   that   subject  to  the  availability  of  federal  financial participation and solely for the period April first, two thousand  seven through  March  thirty-first, two thousand eight, six million dollars in the aggregate of this  sixty  million  dollars  shall  be  allocated  to voluntary  non-profit  hospitals  which  continue  to  provide inpatient services  as  of  April  first,  two  thousand   seven   through   March thirty-first,  two  thousand  eight  and  which  have Medicaid inpatient discharge percentages of less than thirty-five  percent  and  which  had previously  qualified  for  distributions pursuant to paragraph (s-7) of this subdivision. The rate adjustment calculated in accordance with this  paragraph shall be allocated proportionally based on the amount of money the hospital had received in two thousand six.   12.  Provisions for article forty-three insurance law corporations and article forty-four of this chapter organizations.  Except as provided in paragraphs (a) and (b) of this subdivision, general hospital charges for inpatient  and  outpatient  services  to subscribers or beneficiaries of contracts entered into pursuant to the provisions of article forty-three of the insurance law or to members of a  comprehensive  health  services plan  operating pursuant to the provisions of article forty-four of this chapter for patient services rendered shall  not  exceed  the  rates  of payment  approved  by  the  commissioner  for  payments  by such article forty-three   insurance   law   corporations   or   article   forty-four organizations.  No general hospital may demand or request any charge for such  covered services in addition to the charges or rates authorized by this article.  (a) Any general hospital which terminated its contract with an article nine-c insurance law corporation or a comprehensive health services plan after October first, nineteen  hundred  seventy-six  and  prior  to  May first,  nineteen  hundred  seventy-eight,  may not charge subscribers or beneficiaries of contracts entered into pursuant to  the  provisions  of article  forty-three of the insurance law, or members of a comprehensive health services plan operating pursuant to  the  provisions  of  article forty-four   of   this  chapter,  amounts  in  excess  of  the  payments established by such hospital for patient services in accordance with the provisions of paragraph (c) of subdivision one of this  section,  or  in the   event   the  article  forty-three  insurance  law  corporation  or comprehensive health services plan operating pursuant to the  provisions of  article  forty-four of this chapter provides for reimbursement on an expense incurred basis and makes payment directly to such  hospital  for patient  services  for  its  subscribers  or beneficiaries, such article forty-three insurance law corporation or comprehensive  health  services plan  shall  be  an  additional  category of payor of inpatient hospital services whose rates  of  payment  are  determined  in  accordance  with paragraph  (b)  of  subdivision  one of this section based on an imputed rate  of  payment  determined  in  accordance  with  paragraph  (a)   of subdivision one of this section for an article forty-three insurance law corporation,  adjusted for uncovered services, and increased by thirteen percent.  (b) Any general hospital which had  notified  in  writing  an  article nine-c corporation or a comprehensive health services plan prior to June first,  nineteen hundred seventy-eight of its intention to terminate its contract with such corporation or plan in accordance with the  terms  of such  contract,  except  a general hospital subject to the provisions of paragraph (a) of  this  subdivision  may  not  charge  a  subscriber  or beneficiary  of  a  contract  entered into pursuant to the provisions of article forty-three of the insurance law, or a member of a comprehensive health services plan operating pursuant to  the  provisions  of  article forty-four  of  this chapter, after the effective date of termination of such contract, amounts in excess of the  payments  established  by  such hospital  for  patient  services  in  accordance  with the provisions of paragraph (c) of subdivision one of this section, or in  the  event  the article  forty-three  insurance  law corporation or comprehensive health services plan operating pursuant to the provisions of article forty-four of this chapter provides for reimbursement on an expense incurred  basis and makes payment directly to such hospital for patient services for its subscribers  or  beneficiaries,  such  article forty-three insurance law corporation or comprehensive health services plan shall be an additional category of payor of inpatient hospital services whose rates of  payment  are  determined  in  accordance with paragraph (b) of subdivision one of this  section  based  on  an  imputed  rate  of  payment  determined  in accordance  with paragraph (a) of subdivision one of this section for an article  forty-three  insurance  law corporation, adjusted for uncovered services, and increased by thirteen percent.  (c) No general hospital shall refuse to provide  patient  services  to such  subscribers  or  beneficiaries  solely  on  the  grounds  of  such subscription or membership.  (d) The provisions of this subdivision shall also apply to payments to general hospitals by a corporation organized and operating in accordance with  article  forty-three  of  the  insurance  law  for  inpatient  and outpatient  services  on  behalf of subscribers of a foreign corporation which performs similar functions in another state or which belongs to  a national  association  comprised  of  similar  corporations to which the article forty-three corporation also  belongs;  provided,  however,  the foreign  corporation  or  the  laws  of  the  state in which the foreign corporation is organized extends  to  article  forty-three  corporations organized  and  operating  in  this state a reciprocal right to have the foreign corporation make payments to hospitals in that  other  state  on behalf  of  subscribers  of  the article forty-three corporations at the same rate of payment as  that  foreign  corporation  pays  for  its  own subscribers.   * (e)  The  provisions of this subdivision shall not apply to patients discharged on or after January first, nineteen hundred ninety-seven.   * NB Expires December 31, 2023   13.  Restitution  authorization.  In  enforcing  the   provisions   of subdivisions  one  and  twelve of this section, the commissioner may, in addition to the penalties and injunctions set forth in section twelve of this chapter, order that any general hospital  provide  restitution  for any  overpayments  made  by any party. Any hospital may request a formal hearing pursuant to the provisions of section twelve-a of  this  chapter in  the  event  the  hospital  objects  to any order of the commissioner hereunder. The commissioner may direct  that  such  a  hearing  be  held without any request by a hospital.   14.  Bad  debt and charity care allowance. * (a) With the exception of rates of payment for services provided to beneficiaries of  title  XVIII of  the  federal  social  security act (medicare), all rates and general hospital charges, including rates  of  payment  for  state  governmental agencies  provided  all  federal  approvals necessary by federal law and regulation for federal financial  participation  in  payments  made  for beneficiaries  eligible  for  medical  assistance under title XIX of the federal social security act based upon the allowance provided herein  as a  component  of such payments are granted, established for rate periods commencing on or after January first, nineteen hundred eighty-eight  and prior to January first, nineteen hundred ninety-seven in accordance with this  section  shall include the allowance specified in paragraph (c) of this subdivision. The allowance shall be computed on the  basis  of  the operating and capital related components of such rates after trending of the  operating  portion.  For  the  purposes  of  this  subdivision  and subdivision seventeen of this section, major  public  general  hospitals are  defined  as  all  state  operated  general  hospitals,  all general hospitals operated by the New York city health and hospitals corporation as established by chapter one thousand sixteen of the laws  of  nineteen hundred  sixty-nine  as  amended  and all other public general hospitals having annual inpatient operating costs in excess of twenty-five million dollars.   * NB Effective until December 31, 2023    * (a) With the exception of rates of payment for services provided  to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare), all rates and general hospital charges, including  rates  of payment  for  state governmental agencies provided all federal approvals necessary   by   federal   law  and  regulation  for  federal  financial participation in payments made for beneficiaries  eligible  for  medical assistance under title XIX of the federal social security act based upon the  allowance  provided  herein  as  a  component  of such payments are granted, established for rate periods commencing  on  or  after  January first,  nineteen  hundred  eighty-eight  in accordance with this section shall  include  the  allowance  specified  in  paragraph  (c)  of   this subdivision.  The  allowance  shall  be  computed  on  the  basis of the operating and capital related components of such rates after trending of the  operating  portion.  For  the  purposes  of  this  subdivision  and subdivision  seventeen  of  this section, major public general hospitals are defined  as  all  state  operated  general  hospitals,  all  general hospitals operated by the New York city health and hospitals corporation as  established  by chapter one thousand sixteen of the laws of nineteen hundred sixty-nine as amended and all  other  public  general  hospitals having annual inpatient operating costs in excess of twenty-five million dollars.   * NB Effective December 31, 2023  (b)  The  allowance shall be a percentage to reflect the needs for the financing of losses resulting from bad debts and the  costs  of  charity care  of  general  hospitals  within  article  forty-three insurance law regions, or such  other  regions  as  adopted  pursuant  to  subdivision sixteen  of  this  section,  and  within  a  statewide  determination of financial resources to be committed for this purpose.   Need shall be defined as inpatient losses from bad  debts  reduced  to cost and the inpatient costs of charity care increased by any deficit of such  hospital from providing ambulatory services, excluding any portion of such deficit resulting from governmental payments below average visit costs, and revenues and expenses related to the  provision  of  referred ambulatory  services.  Funds  received by major public general hospitals pursuant to article  forty-one  of  the  mental  hygiene  law  shall  be considered  to  have been provided for inpatient hospital deficits only. The council shall adopt rules and regulations, subject to  the  approval of  the  commissioner,  to  establish  uniform  reporting and accounting principles  designed  to  enable  hospitals  to  fairly  and  accurately determine  and  report  losses  from  bad debts and the costs of charity care.  (c) The regional amounts to be included in rates approved for the rate year commencing January first, nineteen hundred  eighty-eight  shall  be equal  to  the  sum of the following two components divided by the total reimbursable inpatient costs for the general hospitals  located  in  the region,  excluding  inpatient  costs  related  to beneficiaries of title XVIII  of  the  federal  social  security  act  (medicare),  and   after application of the trend factor. The first component shall be the result of  the  ratio  between  the  total nominal payment amount in dollars as determined in subparagraph (i) of this paragraph that would be allocated to  voluntary  non-profit,  private  proprietary  and   public   general hospitals  other than major public general hospitals in the region based on a targeted need formula applied in accordance with subparagraphs  (i) and (ii) of this paragraph and the statewide sum of such nominal payment amounts  to voluntary non-profit, private proprietary and public general hospitals other than major public general hospitals applied to the total statewide resources committed for this purpose to regional pools in  the rate  year,  excluding  the total statewide amount allocated in the rate  year for this purpose to major public general  hospitals  in  accordance with subparagraph (iii) of this paragraph. The second component shall be the  dollar  amount  allocated  to major public general hospitals in the region  in  accordance  with  subparagraph  (iii) of this paragraph. The regional amount to be included in the rates approved for the rate  years commencing on or after January first, nineteen hundred eighty-nine shall be  computed  in  the  same  manner  except  that  the base year for the targeted need as specified in subparagraph (i) of this  paragraph  shall be the calendar year which is two years prior to the rate year. For each annual  rate  period  commencing  on  or  after  January first, nineteen hundred eighty-eight, the statewide amount to be available  in  regional pools  for  this  purpose  shall  equal  five and forty-eight hundredths percent of the total hospital reimbursable  inpatient  costs,  excluding inpatient  costs  related to services provided to beneficiaries of title XVIII of the federal social security act  (medicare),  computed  without consideration  of inpatient uncollectible amounts, and after application of the trend factor.  (i) Targeted need shall be defined as the relationship of need to  net patient  service  revenue expressed as a percentage. Net patient service revenue  shall  be  defined  as  net  patient  revenue  attributable  to inpatient   and   outpatient   services  excluding  referred  ambulatory services. For the rate year beginning January  first,  nineteen  hundred eighty-eight   and   ending   December  thirty-first,  nineteen  hundred eighty-eight the scale specified in subparagraph (ii) of this  paragraph shall  be  utilized  to  calculate individual hospital's nominal payment amounts on the  basis  of  the  percentage  relationship  between  their nineteen  hundred  eighty-six  need  and nineteen hundred eighty-six net patient service revenues. The nominal payment amount shall be defined as the  sum  of  the  dollars  attributable  to  the  application   of   an incrementally  increasing  proportion  of  reimbursement  for percentage increases  in  targeted  need  according  to  the  scale  specified   in subparagraph  (ii)  of  this  paragraph.  The sum of the nominal payment amounts for all hospitals in  a  region  shall  be  the  region's  total nominal payment amount.  (ii)  The  scale  utilized  for development of each hospital's nominal payment amount shall be as follows:                                          Percentage of Reimbursement                                         Attributable to that Portion  Targeted Need Percentage                     of Targeted Need          0     -1%                                  35%          1+    -2%                                  50%          2+    -3%                                  65%          3+    -4%                                  85%          4+    -5%                                  90%          5%+                                        95%  (iii) The dollar amount allocated to major public general hospitals in a region in the  rate  years  nineteen  hundred  eighty-eight,  nineteen hundred  eighty-nine  and in that portion of the nineteen hundred ninety rate year beginning on January first and ending on June thirtieth  shall be  one  hundred two percent and in that portion of the nineteen hundred ninety rate  year  beginning  on  July  first  and  ending  on  December thirty-first,  and  in  subsequent  rate  years shall be one hundred ten percent of the result of the application  of  the  ratio  of  the  major public general hospitals' inpatient reimbursable costs within the region to  total  statewide  general  hospital inpatient reimbursable costs, as computed on the basis of  nineteen  hundred  eighty-five  financial  and  statistical   reports   and  excluding  costs  related  to  services  to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare),  to  the  statewide  resources committed for this purpose to regional    pools,   computed   without   consideration   of   inpatient uncollectible amounts.  (iv) Notwithstanding  any  inconsistent  provision  of  this  section, commencing  April  first,  nineteen  hundred  ninety-five  the allowance pursuant to this subdivision  shall  be  a  uniform  regional  allowance percentage of five and forty-eight hundredths percent for all regions.  (d)  In  the  event  the regional percentage bad debt and charity care allowances for general hospitals for a  rate  period  commencing  on  or after   January   first,  nineteen  hundred  ninety-four  determined  in accordance with paragraph (c) of this subdivision to be submitted to bad debt and charity care regional pools established pursuant to subdivision sixteen of this section and deposited  in  accordance  with  subdivision seventeen  of this section do not qualify for waiver pursuant to federal law and regulation related to such  regional  allowance  variations,  in order  for  such allowances to be qualified as a broad-based health care related tax for purposes of the revenues received by the state from such allowances not reducing the amount expended  by  the  state  as  medical assistance  for  purposes  of  federal  financial participation, but the regional percentage allowances for  the  nineteen  hundred  ninety-three rate year do so qualify, then the regional percentage allowances for the regions  for  the  nineteen hundred ninety-three rate year determined in accordance with paragraph (c)  of  this  subdivision  shall  be  further continued for such period for such regions.   14-a.   Supplementary  bad  debt  and  charity  care  adjustment.  (a) Notwithstanding any inconsistent provision of  this  section,  rates  of payment  for  inpatient  hospital  services  for  persons  eligible  for payments made by state governmental agencies for the period April first, nineteen hundred eighty-nine to December thirty-first, nineteen  hundred eighty-nine  and  for each annual period commencing January first during the  period  January  first,  nineteen  hundred   ninety   to   December thirty-first,  nineteen  hundred  ninety-three  applicable  to  patients eligible for federal financial participation  under  title  XIX  of  the federal  social  security act in medical assistance provided pursuant to title eleven of article five of the social services  law  determined  in accordance  with  this  section  for a major public general hospital, as defined in paragraph (a) of subdivision fourteen of this section,  shall include  a supplementary bad debt and charity care adjustment determined in accordance with paragraph (b) of this subdivision provided the  state governmental  agency  or  the  county  government  in which such general hospital is located, or the city of New  York  for  a  general  hospital operated by the New York city health and hospitals corporation, files in such time and manner as may be specified by the commissioner an election for such adjustment for such hospital for each period provided that such election  is subject to the approval of the state director of the budget and  provided  all  federal  approvals  necessary  by  federal  law  and regulation  for  federal  financial  participation  in payments made for beneficiaries eligible for medical assistance under  title  XIX  of  the federal social security act based upon the adjustment provided herein as a component of such payments are granted.  (b)(i)  A  supplementary  bad debt and charity care adjustment for the period  April  first,   nineteen   hundred   eighty-nine   to   December thirty-first,  nineteen  hundred  eighty-nine and for each annual period commencing January first  during  the  period  January  first,  nineteen hundred  ninety  to December thirty-first, nineteen hundred ninety-three for an eligible major public general hospital shall  be  determined  for  each  period  in  accordance  with  rules and regulations adopted by the council  and  approved  by  the  commissioner  based  upon  the   amount calculated by subtracting the amount projected to be distributed to such major  public  general hospital pursuant to paragraph (a) of subdivision seventeen of this section for such period from an amount  calculated  as the  product  of the projected bad debt and charity care nominal payment amount coverage ratio for such period for voluntary non-profit,  private proprietary and public general hospitals other than major public general hospitals  multiplied by the base year bad debt and charity care imputed nominal payment amount for such major public general hospital determined in  accordance  with  the  methodology  provided  in  paragraph  (c)  of subdivision  fourteen  of  this  section  for  calculation  of a nominal payment amount for voluntary non-profit, private proprietary and  public general  hospitals  other  than  major  public  general  hospitals.  The coverage ratio shall be computed as the ratio between  the  sum  of  the dollar value of the amount committed to the regional pools in accordance with paragraph (c) of subdivision fourteen of this section and paragraph (a)  of  subdivision  nineteen  of this section for the rate period that would be allocated to  voluntary  non-profit,  private  proprietary  and public  general  hospitals  other than major public general hospitals in accordance with paragraph (b) of subdivision seventeen of  this  section and the base year nominal payment amount for such hospitals.  (ii)  A supplementary bad debt and charity care adjustment provided in accordance with subparagraph (i) of this paragraph shall be adjusted  to reflect  actual  distributions  pursuant  to  paragraph  (a)  and (b) of subdivision seventeen of this section.   * (c) Notwithstanding any inconsistent provision of this  subdivision, a supplementary bad debt and charity care adjustment shall be determined and  provided  for  each  of  the nineteen hundred ninety-four, nineteen hundred  ninety-five  and  nineteen  hundred  ninety-six  rate  periods, provided that the election pursuant to paragraph (a) of this subdivision is  continued for such period, for a major public general hospital equal to the higher of such adjustment for  the  nineteen  hundred  ninety-one rate  period  or  for the nineteen hundred ninety-three rate period. The adjustment may be made to rates of payment or as aggregate  payments  to an eligible hospital.   * NB Effective until December 31, 2023   * (c)  Notwithstanding any inconsistent provision of this subdivision, a supplementary bad debt and charity care adjustment shall be determined and provided for each of  the  nineteen  hundred  ninety-four,  nineteen hundred  ninety-five  and for the period January first, nineteen hundred ninety-six through June  thirtieth,  nineteen  hundred  ninety-six  rate periods,  provided  that  the election pursuant to paragraph (a) of this subdivision is continued for such period, for  a  major  public  general hospital equal to the higher of such adjustment for the nineteen hundred ninety-one  rate  period  or  for the nineteen hundred ninety-three rate period. The adjustment may be made to rates of payment or  as  aggregate payments to an eligible hospital.   * NB Effective December 31, 2023   * (d)   Notwithstanding   any   inconsistent  provision  of  law,  the provisions of paragraphs (a), (b) and (c) of this subdivision shall  not apply  to  payments  for  patients discharged on or after January first, nineteen hundred ninety-seven.   * NB Expires December 31, 2023   14-b. General health care services allowance. (a) With  the  exception of  rates  of  payment  for  services provided to beneficiaries of title XVIII of the federal social  security  act  (medicare),  all  rates  and general  hospital  charges established for rate periods commencing on or  after January first, nineteen hundred ninety-one in accordance with this section shall include a percentage allowance of the  general  hospital's reimbursable  inpatient  costs,  excluding  inpatient  costs  related to services  provided to beneficiaries of title XVIII of the federal social security act (medicare), computed  without  consideration  of  inpatient uncollectible  amounts,  and  after  application of the trend factor, as follows:  (i) for the nineteen hundred ninety-one, nineteen  hundred  ninety-two and   nineteen  hundred  ninety-three  rate  periods,  an  allowance  of twenty-three hundredths of one percent;  (ii) for the nineteen hundred ninety-four rate period, an allowance of six hundred fourteen thousandths of one percent;  (iii) for the January first, nineteen hundred ninety-five through June thirtieth, nineteen hundred ninety-five rate period, an allowance of six hundred thirty-seven thousandths of one percent  (iv) for the July first, nineteen hundred ninety-five through December thirty-first, nineteen hundred ninety-five rate period, an allowance  of one and forty-two hundredths percent; and   * (v)  for  the  January  first,  nineteen  hundred ninety-six through December thirty-first,  nineteen  hundred  ninety-six  rate  period,  an allowance of one and nine hundredths percent.   * NB Effective until December 31, 2023   * (v)  for the January first, nineteen hundred ninety-six through June thirtieth, nineteen hundred ninety-six rate period, an allowance of  one and nine hundredths percent.   * NB Effective December 31, 2023  (b)  For  rate  periods  beginning on or after January first, nineteen hundred  ninety-one  but  prior  to  January  first,  nineteen   hundred ninety-four,  funds  will  be accumulated and made available in regional pools  created  by  the  commissioner  for  regional  distributions   in accordance  with  section  twenty-eight hundred seven-bb of this chapter through the submission by or on  behalf  of  general  hospitals  of  the allowance included in rates and charges in accordance with paragraph (a) of this subdivision. Such regions shall be those established pursuant to paragraph (b) of subdivision sixteen of this section. The regional pools may  be  administered in accordance with the provisions of paragraph (c) of subdivision sixteen of  this  section  applicable  to  bad  debt  and charity  care  regional  pools.  Payments  by  or  on  behalf of general hospitals to regional pools shall be due and arrearages shall be treated in accordance with the provisions of subdivision twenty of this  section applicable to bad debt and charity care regional pools.  (c) If on September thirtieth, nineteen hundred ninety-four, any funds accumulated  over  the period January first, nineteen hundred ninety-one through December thirty-first, nineteen hundred ninety-three are  unused or  uncommitted  for  the  allocations provided for in this subdivision, such unused or  uncommitted  funds  shall  be  reallocated  for  use  in accordance with the provisions of subdivision seventeen of this section.  (d)  For  the  rate  periods  commencing  on  or  after January first, nineteen hundred ninety-four, funds will be accumulated in  a  statewide pool  created by the commissioner through the submission by or on behalf of general hospitals of the allowance included in rates and  charges  in accordance  with paragraph (a) of this subdivision, for distributions in accordance with subdivision nineteen-a of this section.  (e)  The  commissioner  is  authorized  to  contract   with   a   pool administrator designated in accordance with paragraph (c) of subdivision sixteen  of this section or, if not available, such other administrators as the commissioner shall designate, to  receive  funds  for  the  pools created  pursuant  to  this  subdivision  and  to  distribute  funds  in  accordance with this subdivision  and  subdivision  nineteen-a  of  this section.  If  a pool administrator is designated, the commissioner shall conduct or cause to be conducted an annual  audit  of  the  receipt  and distribution  of pool funds. The reasonable costs and expenses of a pool administrator as  approved  by  the  commissioner,  not  to  exceed  for personnel  services  on  an  annual  basis two hundred thousand dollars, shall be paid from the pooled funds.  (f) (i) Payments to the pools by or on behalf of general hospitals  of funds  due  based  on  the  allowances  provided in accordance with this subdivision  shall  be  due  in  accordance  with  the   provisions   of subdivision  twenty  of this section in the same manner as applicable to bad debt and charity care regional pools. Arrearages in payments due may be collected and interest and penalties due shall be determined and  may be  collected  by  the commissioner in accordance with the provisions of subdivision twenty of this section in the same manner as  applicable  to bad debt and charity care regional pools.  (ii)  Notwithstanding  any  inconsistent provision of this section, as shall be necessary to obtain federal financial participation in  medical assistance  expenditures  in  accordance  with  title XIX of the federal social security  act,  the  allowances  included  in  rates  of  payment pursuant  to this subdivision on behalf of patients eligible for medical assistance pursuant to title  eleven  of  article  five  of  the  social services  law  shall  be  withheld  from  medical assistance payments to general hospitals and paid to pools on behalf of the  general  hospitals where a general hospital elects such withholding in such time and manner as  specified  by  the commissioner, and in the event a general hospital does not elect such withholding, payments by such general hospital to  a pool  based  on  an  allowance  received for medical assistance patients shall be due within five days of receipt of such funds.  Funds  withheld by  a  payor and paid to a pool on behalf of a general hospital shall be considered received by such general hospital and paid  to  the  pool  by such general hospital for all purposes.  (g)  The  allowances  provided  pursuant  to  paragraph  (a)  of  this subdivision  shall  be  effective  and  implemented  for   purposes   of determining  rates of payment for state governmental agencies contingent on receipt  of  all  federal  approvals  necessary  by  federal  law  or regulations  for  federal  financial  participation in payments made for beneficiaries eligible for medical assistance under  title  XIX  of  the federal social security act based upon such allowances as a component of such  payments.  If  such  federal  approvals  are  not granted for such allowances  or  components  thereof,  rates   of   payment   for   state governmental  agencies  shall  be  determined  in  accordance  with  the provisions of this section without consideration of such  allowances  or such  components  plus  an  adjustment  not subject to federal financial participation equal to one-half of the difference between such rates  of payment   determined   without   consideration  of  such  allowances  or components and a rate of payment determined based on such allowances  or components.  The  pools  established  pursuant to this subdivision shall refund to the state governmental  agency  from  pool  reserves,  current funds or future receipts any overpayment received based on a retroactive reduction pursuant to this paragraph in the allowances.  (h)  The  allowances  provided  pursuant  to  paragraph  (a)  of  this subdivision or components thereof shall be of no force  and  effect  and shall be deemed to have been null and void as of January first, nineteen hundred  ninety-four  in  the  event  the secretary of the department of health and human  services  determines  that  such  allowances  or  such components  thereof  are  an  impermissible  health care related tax for purposes  of   the   federal   medicaid   voluntary   contribution   and  provider-specific  tax  amendments  of  nineteen  hundred ninety-one for purposes of such funds reducing the amount deemed expended by the  state as medical assistance for purposes of federal financial participation.   14-c.  Bad  debt and charity care allowance for financially distressed hospitals. * (a) With the exception of rates  of  payment  for  services provided  to beneficiaries of title XVIII of the federal social security act (medicare), all rates and general hospital charges  established  for rate  periods  commencing  on  or  after January first, nineteen hundred ninety-one but prior to January first, nineteen hundred  ninety-four  in accordance  with  this section shall include an allowance of two hundred thirty-five thousandths of one percent; and for the rate periods  during the  period January first, nineteen hundred ninety-four through December thirty-first, nineteen hundred ninety-six an allowance of three  hundred twenty-five  thousandths  of  one  percent  of  the  general  hospital's reimbursable inpatient  costs,  excluding  inpatient  costs  related  to services  provided to beneficiaries of title XVIII of the federal social security act (medicare), computed  without  consideration  of  inpatient uncollectible amounts, and after application of the trend factor.   * NB Effective until December 31, 2023   * (a)  With the exception of rates of payment for services provided to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare),  all rates and general hospital charges established for rate periods  commencing  on  or  after  January  first,   nineteen   hundred ninety-one  but  prior to January first, nineteen hundred ninety-four in accordance with this section shall include an allowance of  two  hundred thirty-five  thousandths of one percent; and for the rate periods during the period January first,  nineteen  hundred  ninety-four  through  June thirtieth,  nineteen  hundred  ninety-six  an allowance of three hundred twenty-five  thousandths  of  one  percent  of  the  general  hospital's reimbursable  inpatient  costs,  excluding  inpatient  costs  related to services provided to beneficiaries of title XVIII of the federal  social security  act  (medicare),  computed  without consideration of inpatient uncollectible amounts, and after application of the trend factor.   * NB Effective December 31, 2023  (b) A statewide pool shall be created through the submissions by or on behalf of general hospitals of  the  allowance  included  in  rates  and charges  in  accordance  with  paragraph  (a) of this subdivision. Funds accumulated in the statewide pool, including income from invested funds, shall be deposited  by  the  commissioner  and  credited  to  a  special revenue-other  fund  to be established by the comptroller. To the extent of funds appropriated  therefor,  funds  shall  be  made  available  for distributions  by or on behalf of the state, as payments under the state medical assistance program provided pursuant to title eleven of  article five  of  the  social  services law, from the statewide pool in the same manner as  distributions  made  in  accordance  with  paragraph  (c)  of subdivision  nineteen  of  this  section.  The  statewide  pools  may be administered in accordance with  the  provisions  of  paragraph  (c)  of subdivision  sixteen  of this section applicable to bad debt and charity care regional pools. Payments by or on behalf of  general  hospitals  to statewide  pools  shall  be  due  and arrearages, interest and penalties shall be treated in accordance with the provisions of subdivision twenty of this section applicable to bad debt and charity care regional pools.  (c)  Notwithstanding  any   inconsistent   provision   of   law,   the commissioner  may  allocate  and  distribute  funds  accumulated  in the statewide  pool  created  pursuant  to  this   subdivision   and   funds accumulated  in the statewide pool created by the assessments authorized in accordance with subdivision eighteen of this  section  and  available for   distribution   in  accordance  with  paragraphs  (c)  and  (d)  of  subdivision nineteen of  this  section  for  contracts  for  independent management   audits   of  financially  distressed  hospitals,  provided, however, that the total amount for audits  pursuant  to  this  paragraph shall  not  exceed  two  million  five hundred thousand dollars over the period January first,  nineteen  hundred  ninety-four  through  December thirty-first,  nineteen hundred ninety-five.  Copies of management audit reports of financially distressed hospitals shall  be  provided  by  the commissioner to the chairs of the senate and assembly health committees.   14-d.    Supplementary    low   income   patient   adjustment.   * (a) Notwithstanding any inconsistent provision of this section, payment  for inpatient  hospital  services  for persons eligible for payments made by state governmental agencies for rate periods during the  period  January first,   nineteen  hundred  ninety-one  through  December  thirty-first, nineteen hundred ninety-six applicable to patients eligible for  federal financial  participation  under title XIX of the federal social security act in medical assistance provided pursuant to title eleven  of  article five  of  the  social  services  law  determined in accordance with this section shall include for eligible general hospitals a supplementary low income patient adjustment determined in accordance with paragraph (b) of this subdivision, provided all federal approvals  necessary  by  federal law  and regulation for federal financial participation in payments made for beneficiaries eligible for medical assistance under title XIX of the federal social security act based upon the adjustment provided herein as a component of such payments are granted. The adjustment may be made  to rates of payment or as aggregate payments to an eligible hospital.   * NB Effective until December 31, 2023   * (a)  Notwithstanding  any  inconsistent  provision  of this section, payment  for  inpatient  hospital  services  for  persons  eligible  for payments made by state governmental agencies for rate periods during the period   January   first,   nineteen  hundred  ninety-one  through  June thirtieth, nineteen hundred ninety-six applicable to  patients  eligible for  federal  financial  participation  under  title  XIX of the federal social security act in medical assistance  provided  pursuant  to  title eleven  of  article  five  of  the  social  services  law  determined in accordance  with  this  section  shall  include  for  eligible   general hospitals  a  supplementary  low income patient adjustment determined in accordance with paragraph (b) of this subdivision, provided all  federal approvals  necessary by federal law and regulation for federal financial participation in payments made for beneficiaries  eligible  for  medical assistance under title XIX of the federal social security act based upon the  adjustment  provided  herein  as  a  component of such payments are granted. The adjustment may be made to rates of payment or as  aggregate payments to an eligible hospital.   * NB Effective December 31, 2023   * (b)  A  supplementary  low  income patient adjustment for the period January   first,   nineteen   hundred   ninety-one   through    December thirty-first, nineteen hundred ninety-three shall be determined, subject to  the  provisions  of subparagraph (iv) of this paragraph, and for the period January first,  nineteen  hundred  ninety-four  through  December thirty-first,  nineteen  hundred ninety-six shall be determined for each eligible hospital according to the scale specified in subparagraph (iii) of this paragraph based upon the amount calculated  by  multiplying  the applicable  supplemental  percentage  coverage  of  need  amount for the hospital  by  the  hospital's  need  as  defined  in  paragraph  (b)  of subdivision  fourteen  of  this section; provided, however, that for the period January first,  nineteen  hundred  ninety-four  through  December thirty-first,  nineteen hundred ninety-six if the sum of the adjustments pursuant to clause (C) of subparagraph (iii)  of  this  paragraph  would  exceed thirty-six million dollars for a rate year on an annualized basis the  supplemental  percentage  coverage of need scale pursuant to clause (C) of subparagraph (iii) of this paragraph shall be reduced  on  a  pro rata  basis  so  that  the sum of such adjustments provided for the rate year on an annualized basis shall not exceed thirty-six million dollars.  (i) The low income patient percentage of a general hospital  shall  be defined  as  the  ratio  of  the sum of inpatient discharges of patients eligible for medical assistance pursuant to title eleven of article five of the  social  services  law  plus  inpatient  discharges  of  self-pay patients  plus  inpatient discharges of charity care patients divided by total inpatient discharges expressed as a  percentage.  For  the  period January    first,   nineteen   hundred   ninety-one   through   December thirty-first, nineteen hundred ninety-three, the  percentages  shall  be calculated  based on base year nineteen hundred eighty-nine, received by the department no later than November first,  nineteen  hundred  ninety, data  from  the  statewide  planning  and  research  cooperative  system consistent with data submitted in accordance with  section  twenty-eight hundred  five-a  of this article. For the period January first, nineteen hundred ninety-four  through  December  thirty-first,  nineteen  hundred ninety-six,  the  percentages  shall  be  calculated  based on base year nineteen hundred ninety-one, received by the department  no  later  than November  first,  nineteen hundred ninety-three, data from the statewide planning and research cooperative system consistent with data  submitted in  accordance with section twenty-eight hundred five-a of this article. In order to be eligible for an adjustment pursuant to this  subdivision, a  hospital  must  maintain  its collection efforts to obtain payment in full from self-pay patients.  (ii) For the period January first, nineteen hundred ninety-one through December thirty-first,  nineteen  hundred  ninety-three,  hospital  need shall  be  calculated  based  on  base year nineteen hundred eighty-nine data. For the period January first, nineteen hundred ninety-four through December thirty-first, nineteen hundred ninety-six, hospital need  shall be calculated based on base year nineteen hundred ninety-one data.  (iii)(A)   The   scale   utilized  for  development  of  a  hospital's supplementary low income patient adjustment shall be as follows for  the period   January   first,   nineteen  hundred  ninety-one  through  June thirtieth, nineteen hundred ninety-one:          Low Income                 Supplemental Percentage     Patient Percentage                 Coverage of Need          50+  55%                               5%          55+  60%                              10%          60+  65%                              15%          65+  70%                              22.5%          70+  75%                              30%          75+  80%                              37.5%          80+                                   45%  (B) The scale utilized for development of a  hospital's  supplementary low  income  adjustment  shall  be as follows for the period July first, nineteen hundred  ninety-one  for  a  public  general  hospital  through December  thirty-first,  nineteen hundred ninety-six and for a voluntary non-profit or a private proprietary general hospital  through  September thirtieth, nineteen hundred ninety-two:         Low Income                   Supplemental Percentage     Patient Percentage                 Coverage of Need          35+  55%                              20%          55+  60%                              25%          60+  65%                              30%          65+  70%                              37.5%           70+                                   45%  (C)  The  scale  utilized for development of a voluntary non-profit or private proprietary general hospital's supplementary low income  patient adjustment  shall  be  as follows for the period October first, nineteen hundred  ninety-two  through  March   thirty-first,   nineteen   hundred ninety-three   and  for  the  period  January  first,  nineteen  hundred ninety-four through December thirty-first, nineteen hundred ninety-six:         Low Income                   Supplemental Percentage     Patient Percentage                 Coverage of Need          35+  50%                              10%          50+  55%                              20%          55+  60%                              25%          60+  65%                              30%          65+  70%                              37.5%          70+                                   45%  (D) The scale utilized for development of a  voluntary  non-profit  or private  proprietary general hospital's supplementary low income patient adjustment for the period May fifteenth, nineteen  hundred  ninety-three through December thirty-first, nineteen hundred ninety-three shall be at one  hundred  twenty  percent of the supplemental percentage coverage of need scale specified in clause (C) of this subparagraph.  (iv)  A  supplementary  low  income  patient   adjustment   determined according to the scale specified in subparagraph (iii) of this paragraph shall  be  limited  for  rate  periods  during the period January first, nineteen hundred  ninety-one  through  December  thirty-first,  nineteen hundred  ninety-three  such  that  the  amount of such adjustment for an eligible hospital, plus the amount committed to the  regional  pools  in accordance  with  paragraph  (c) of subdivision fourteen of this section and paragraph (a) of subdivision nineteen of this section for  the  rate period  that  would  be allocated to such hospital, plus, if applicable, any distribution for the  rate  period  pursuant  to  paragraph  (d)  of subdivision  nineteen  of this section for such hospital, and plus for a major public general hospital the amount of any supplementary  bad  debt and  charity care adjustment provided pursuant to subdivision fourteen-a of this section for the rate period shall not exceed ninety  percent  of need.  (v)  The  provisions  of this subdivision shall not apply to a general hospital eligible for distributions made pursuant to  paragraph  (c)  of subdivision nineteen of this section.   * NB Effective until December 31, 2023   * (b)  A  supplementary  low  income patient adjustment for the period January   first,   nineteen   hundred   ninety-one   through    December thirty-first, nineteen hundred ninety-three shall be determined, subject to  the  provisions  of subparagraph (iv) of this paragraph, and for the period  January  first,  nineteen  hundred  ninety-four   through   June thirtieth,  nineteen  hundred  ninety-six  shall  be determined for each eligible hospital according to the scale specified in subparagraph (iii) of this paragraph based upon the amount calculated  by  multiplying  the applicable  supplemental  percentage  coverage  of  need  amount for the hospital  by  the  hospital's  need  as  defined  in  paragraph  (b)  of subdivision  fourteen  of  this section; provided, however, that for the period  January  first,  nineteen  hundred  ninety-four   through   June thirtieth,  nineteen  hundred  ninety-six  if the sum of the adjustments pursuant to clause (C) of subparagraph (iii)  of  this  paragraph  would exceed thirty-six million dollars for a rate year on an annualized basis the  supplemental  percentage  coverage of need scale pursuant to clause (C) of subparagraph (iii) of this paragraph shall be reduced  on  a  pro  rate  basis  so  that  the sum of such adjustments provided for the rate year on an annualized basis shall not exceed thirty-six million dollars.  (i)  The  low income patient percentage of a general hospital shall be defined as the ratio of the sum  of  inpatient  discharges  of  patients eligible for medical assistance pursuant to title eleven of article five of  the  social  services  law  plus  inpatient  discharges  of self-pay patients plus inpatient discharges of charity care patients  divided  by total  inpatient  discharges  expressed  as a percentage. For the period January   first,   nineteen   hundred   ninety-one   through    December thirty-first,  nineteen  hundred  ninety-three, the percentages shall be calculated based on base year nineteen hundred eighty-nine, received  by the  department  no  later than November first, nineteen hundred ninety, data  from  the  statewide  planning  and  research  cooperative  system consistent  with  data submitted in accordance with section twenty-eight hundred five-a of this article. For the period January  first,  nineteen hundred ninety-four through June thirtieth, nineteen hundred ninety-six, the  percentages shall be calculated based on base year nineteen hundred ninety-one, received by the department no  later  than  November  first, nineteen  hundred  ninety-three,  data  from  the statewide planning and research cooperative system consistent with data submitted in accordance with section twenty-eight hundred five-a of this article. In order to be eligible for an adjustment pursuant to this subdivision, a hospital must maintain its collection efforts to obtain payment in full from  self-pay patients.  (ii) For the period January first, nineteen hundred ninety-one through December  thirty-first,  nineteen  hundred  ninety-three,  hospital need shall be calculated based on  base  year  nineteen  hundred  eighty-nine data. For the period January first, nineteen hundred ninety-four through June  thirtieth,  nineteen  hundred  ninety-six,  hospital need shall be calculated based on base year nineteen hundred ninety-one data.  (iii)(A)  The  scale  utilized  for  development   of   a   hospital's supplementary  low income patient adjustment shall be as follows for the period  January  first,  nineteen  hundred   ninety-one   through   June thirtieth, nineteen hundred ninety-one:         Low Income                   Supplemental Percentage     Patient Percentage                 Coverage of Need          50+  55%                               5%          55+  60%                              10%          60+  65%                              15%          65+  70%                              22.5%          70+  75%                              30%          75+  80%                              37.5%          80+                                   45%  (B)  The  scale utilized for development of a hospital's supplementary low income adjustment shall be as follows for  the  period  July  first, nineteen  hundred  ninety-one for a public general hospital through June thirtieth, nineteen hundred ninety-six and for a voluntary non-profit or a private proprietary  general  hospital  through  September  thirtieth, nineteen hundred ninety-two:         Low Income                   Supplemental Percentage     Patient Percentage                 Coverage of Need          35+  55%                              20%          55+  60%                              25%          60+  65%                              30%          65+  70%                              37.5%          70+                                   45%  (C)  The  scale  utilized for development of a voluntary non-profit or private proprietary general hospital's supplementary low income  patient  adjustment  shall  be  as follows for the period October first, nineteen hundred  ninety-two  through  March   thirty-first,   nineteen   hundred ninety-three   and  for  the  period  January  first,  nineteen  hundred ninety-four through June thirtieth, nineteen hundred ninety-six:         Low Income                   Supplemental Percentage     Patient Percentage                 Coverage of Need          35+  50%                              10%          50+  55%                              20%          55+  60%                              25%          60+  65%                              30%          65+  70%                              37.5%          70+                                   45%  (D)  The  scale  utilized for development of a voluntary non-profit or private proprietary general hospital's supplementary low income  patient adjustment  for  the period May fifteenth, nineteen hundred ninety-three through December thirty-first, nineteen hundred ninety-three shall be at one hundred twenty percent of the supplemental  percentage  coverage  of need scale specified in clause (C) of this subparagraph.  (iv)   A   supplementary  low  income  patient  adjustment  determined according to the scale specified in subparagraph (iii) of this paragraph shall be limited for rate  periods  during  the  period  January  first, nineteen  hundred  ninety-one  through  December  thirty-first, nineteen hundred ninety-three such that the amount  of  such  adjustment  for  an eligible  hospital,  plus  the amount committed to the regional pools in accordance with paragraph (c) of subdivision fourteen  of  this  section and  paragraph  (a) of subdivision nineteen of this section for the rate period that would be allocated to such hospital,  plus,  if  applicable, any  distribution  for  the  rate  period  pursuant  to paragraph (d) of subdivision nineteen of this section for such hospital, and plus  for  a major  public  general hospital the amount of any supplementary bad debt and charity care adjustment provided pursuant to subdivision  fourteen-a of  this  section for the rate period shall not exceed ninety percent of need.  (v) The provisions of this subdivision shall not apply  to  a  general hospital  eligible  for  distributions made pursuant to paragraph (c) of subdivision nineteen of this section.   * NB Effective December 31, 2023  (c)  A  supplementary  low  income  patient  adjustment  provided   in accordance  with  this  subdivision  for  rate periods during the period January   first,   nineteen   hundred   ninety-one   through    December thirty-first, nineteen hundred ninety-three shall be adjusted to reflect actual  distributions  pursuant to paragraphs (a) and (b) of subdivision seventeen of this section and paragraph (d) of subdivision  nineteen  of this section and adjustments provided pursuant to subdivision fourteen-a of this section.  (d)  Notwithstanding  any  inconsistent  provision of law, a voluntary non-profit or proprietary general hospital where the low income  patient percentage,   as  determined  in  accordance  with  provisions  of  this subdivision, is between thirty-five  and  sixty-five  percent  shall  be charged  an assessment which for the period July first, nineteen hundred ninety-one through December thirty-first,  nineteen  hundred  ninety-one shall  equal five percent of the general hospital's bad debt and charity care need as determined in accordance with paragraph (b) of  subdivision fourteen  of  this  section  and  for the period January first, nineteen hundred  ninety-two  through  September  thirtieth,   nineteen   hundred ninety-two  shall  equal  seven  and  one-half  percent  of  the general hospital's bad debt and charity care need as  determined  in  accordance with  paragraph  (b)  of  subdivision  fourteen  of  this  section. Such  assessment shall be paid to the commissioner or his  designee  prior  to October first, nineteen hundred ninety-two in accordance with a schedule established  by the commissioner. The assessments may be administered in accordance  with  the provisions of paragraph (c) of subdivision sixteen of this section applicable to bad debt and charity care regional  pools. Payments of the assessments shall be due and arrearages shall be treated in  accordance with the provisions of subdivision twenty of this section applicable  to  bad  debt  and  charity  care  regional   pools.   Funds accumulated  shall  be deposited by the commissioner and credited to the department of social services medical assistance program general fund  - local assistance account appropriation.   * (e)   Notwithstanding   any   inconsistent  provision  of  law,  the provisions of paragraphs (a) and (b) of this subdivision shall not apply to payments for patients discharged on or after January first,  nineteen hundred ninety-seven.   * NB Expires December 31, 2023   * 14-f.    Public   general   hospital   indigent   care   adjustment. Notwithstanding any inconsistent provision of this section  and  subject to  the  availability  of  federal  financial participation, payment for inpatient hospital services for persons eligible for  payments  made  by state  governmental  agencies  for  the  period  January first, nineteen hundred ninety-seven through  December  thirty-first,  nineteen  hundred ninety-nine  and  periods  on  and  after  January  first,  two thousand applicable to patients  eligible  for  federal  financial  participation under title XIX of the federal social security act in medical assistance provided pursuant to title eleven of article five of the social services law  determined  in  accordance  with  this  section  shall  include for eligible public general hospitals a  public  general  hospital  indigent care  adjustment  equal  to  the  aggregate  amount  of  the adjustments provided for such public general hospital for the period January  first, nineteen  hundred  ninety-six  through  December  thirty-first, nineteen hundred ninety-six pursuant to subdivisions fourteen-a and fourteen-d of this section on an annualized basis, provided, however, that for periods on and after January first, two thousand thirteen an  annual  amount  of four hundred twelve million dollars shall be allocated to eligible major public  hospitals  based  on  each  hospital's  proportionate  share  of medicaid and uninsured losses to total medicaid and uninsured losses for all eligible major public hospitals, net of any  disproportionate  share hospital  payments  received  pursuant  to sections twenty-eight hundred seven-k and twenty-eight hundred seven-w of this article. The adjustment may be made to rates of payment or as aggregate payments to an  eligible hospital.   * NB Effective until December 31, 2023   * 14-f.    Public   general   hospital   indigent   care   adjustment. Notwithstanding any inconsistent provision of this section, payment  for inpatient  hospital  services  for persons eligible for payments made by state governmental agencies  for  the  period  January  first,  nineteen hundred  ninety-seven  through  December  thirty-first, nineteen hundred ninety-nine  applicable  to  patients  eligible  for  federal  financial participation  under  title  XIX  of  the federal social security act in medical assistance provided pursuant to title eleven of article five  of the social services law determined in accordance with this section shall include  for eligible public general hospitals a public general hospital indigent  care  adjustment  equal  to  the  aggregate  amount   of   the adjustments  provided  for  such  public general hospital for the period January   first,   nineteen   hundred   ninety-six   through    December thirty-first,  nineteen  hundred  ninety-six  pursuant  to  subdivisions fourteen-a and fourteen-d  of  this  section  on  an  annualized  basis,  provided  all  federal approvals necessary by federal law and regulation for federal financial participation in payments made  for  beneficiaries eligible  for  medical  assistance under title XIX of the federal social security act based upon the adjustment provided herein as a component of such  payments  are  granted.  The  adjustment  may  be made to rates of payment or as aggregate payments to an eligible hospital.   * NB Effective and repealed December 31, 2023   15. Special provisions for payments by governmental agencies.  In  the event   that  federal  financial  participation  in  payments  made  for beneficiaries eligible for medical assistance under  title  XIX  of  the federal  social  security  act  based  upon  the  allowance specified in paragraph (c) of subdivision fourteen of this section as a component  of such  payments  is  not  approved  by  the  federal government, rates of payment by governmental agencies for the  operating  cost  component  of general hospital inpatient services shall be increased for each hospital by  the same percentage allowance as each hospital's federal fiscal year nineteen hundred eighty-seven disproportionate share payment  adjustment factor  for revenues received from services provided to beneficiaries of title XVIII of the federal social security act (medicare) as  determined in   accordance   with   the  provisions  of  section  eighteen  hundred eighty-six-d  of  title  XVIII  of  the  federal  social  security   act (medicare).   Increased   amounts   received  by  general  hospitals  in accordance with the  provision  of  this  subdivision  shall  be  offset against  distributions to such hospitals that were made or would be made pursuant to the  provisions  contained  in  subdivisions  seventeen  and nineteen  of this section. In the event that distributions had been made to such hospitals pursuant to such subdivisions, the hospital shall,  on a  proportional  basis,  return to the pool from which the distributions were made an amount equal to the increased amounts received  under  this subdivision  to  the  extent  that  such increased amounts do not exceed distributions made. Funds in the statewide pool  created  in  accordance with  subdivision  sixteen  of  this  section,  which  would  have  been distributed in accordance with paragraph (c) of subdivision nineteen  of this  section  if the provisions of this subdivision were not in effect, less any amounts not distributed as the result of the offset  provisions of this subdivision shall be distributed to regional pools to the extent that  such  funds  are available and necessary to maintain regional pool distributions, with consideration  of  the  offset  provisions  in  this subdivision,  at  the  levels  that  would  be available pursuant to the provisions of subdivision fourteen of this section if the provisions  of this subdivision did not apply.   16.  Bad debt and charity care regional pools and bad debt and charity care and capital  statewide  pool,  general.  (a)  Funds  will  be  made available  in  bad  debt  and charity care regional pools created by the commissioner for distributions in accordance with subdivision  seventeen of  this  section  through  the  submissions  by or on behalf of general hospitals of the allowance included in rates and charges  in  accordance with  paragraph  (c) of subdivision fourteen of this section and through the transfer of funds available from the bad debt and charity  care  and capital  statewide  pool in accordance with paragraph (a) of subdivision nineteen of this section. Funds will be made available for distributions in accordance with subdivision nineteen of this section from a bad  debt and  charity care and capital statewide pool created by the commissioner through the submissions by  general  hospitals  of  the  amount  of  the assessments  authorized  in accordance with subdivision eighteen of this section.  (b) The regions are established as the article  forty-three  insurance plan  regions,  with  the  exception  that the southern sixteen counties  shall be divided into three regions for  the  purposes  of  subdivisions fourteen  and seventeen of this section with separate regions consisting of Richmond, Manhattan, Bronx, Queens and  Kings  counties;  Nassau  and Suffolk  counties;  and  Delaware,  Columbia,  Ulster, Sullivan, Orange, Dutchess, Putnam, Rockland and Westchester counties. Such regions  shall be  the  same  regions established and in effect January first, nineteen hundred eighty-five. The council with the approval of  the  commissioner may  combine  regions, with the exception of the above specified regions for the southern sixteen  counties,  upon  application  of  the  article forty-three  insurance  law  plans  involved  and  a  demonstration that significant inequities would not occur.  (c) For periods  prior  to  January  first,  two  thousand  five,  the commissioner  and  the commissioner of social services are authorized to contract with the article forty-three insurance law  plans,  or  if  not available   such  other  administrators  as  the  commissioner  and  the commissioner of social services shall designate, to  receive  funds  for the  bad  debt  and  charity care regional pools and/or the bad debt and charity care and capital statewide pool and distribute funds  from  such pools. In the event contracts with the article forty-three insurance law plans   or   other   commissioners'   designees   are  effectuated,  the commissioner and the  commissioner  of  social  services  shall  jointly conduct  or  cause  to  be  conducted  annual  audits of the receipt and distribution of the pooled funds. The reasonable costs and expenses of a pool administrator as approved by the commissioner and the  commissioner of  social  services,  not to exceed for personnel services on an annual basis four hundred thousand dollars for all pools, shall  be  paid  from the  pooled  funds. Such pool administrator or pool administrators shall be acting on behalf of the state  medical  assistance  program  provided pursuant  to  title eleven of article five of the social services law in the distribution  to  hospitals  pursuant  to  subdivisions  fourteen-c, seventeen  and  paragraphs  (c)  and (d) of subdivision nineteen of this section of pooled funds.  (d) In order for a general hospital to participate in the distribution of funds from the pools, the general hospital must implement  collection policies and procedures approved by the commissioner.  (e) In order for a general hospital to be eligible for distribution of funds  from  the pools, such general hospital if it provides obstetrical care and services must agree to participate in a program approved by the department for the provision of prenatal care to  persons  eligible  for medical  assistance or medically indigent persons if requested by such a program. Nothing  stated  herein  shall  require  a  hospital  to  grant admitting  privileges  to a physician solely because such person is part of an approved program. The participation of hospitals  in  an  approved program shall include, but not be limited to:  (i)   arrangements   with   designated  prenatal  care  providers  for prebooking pregnant women for approximate delivery time,  and  provision of  staff  and facilities for the delivery and necessary postpartum care for women and infants involved in such programs;  (ii) a system  for  medical  record  transfer  from  a  prenatal  care provider  to  hospital  staff  participating  in  delivery  and  for the transfer of information regarding hospital delivery and care back to the prenatal care provider for postpartum follow-up; and  (iii) an agreement with designated prenatal care providers  to  accept the  care  of  high  risk patients on a referral basis and/or to provide special tests and procedures  which  are  not  ordinarily  available  to prenatal  care  clinics  if  such hospital is capable of caring for high risk patients and/or providing special tests and procedures.  (f) The council may adopt regulations subject to the approval  of  the commissioner  to  allow  advanced  distributions  from  these pools to a general  hospital  qualifying  for  distributions  in  accordance   with paragraph  (c)  of  subdivision  nineteen  of  this  section, based on a demonstration  by  the  hospital  that  there is an inability to finance current obligations and obtain needed working capital.   * (g)  Notwithstanding  any  inconsistent  provision  of  law  to  the contrary, from interest heretofore earned or hereinafter earned on funds in bad debt and charity care regional pools and the bad debt and charity care  and  capital  statewide pool established pursuant to this section, such amounts as shall be necessary, within amounts  appropriated,  shall be  reallocated  to,  and the state comptroller is hereby authorized and directed to receive for deposit to, the  credit  of  the  department  of health's  special  revenue  fund  - other, hospital based grants program account, for purposes  of  services  and  expenses  related  to  general hospital  based  grant  programs  for  the  period April first, nineteen hundred ninety-four through June thirtieth, nineteen hundred  ninety-six and for the period July first, nineteen hundred ninety-six through March thirty-first, nineteen hundred ninety-seven.   * NB Effective until December 31, 2023   * (g)  Notwithstanding  any  inconsistent  provision  of  law  to  the contrary, from interest heretofore earned or hereinafter earned on funds in bad debt and charity care regional pools and the bad debt and charity care and capital statewide pool established pursuant  to  this  section, such  amounts  as shall be necessary, within amounts appropriated, shall be reallocated to, and the state comptroller is  hereby  authorized  and directed  to  receive  for  deposit  to, the credit of the department of health's special revenue fund - other,  hospital  based  grants  program account,  for  purposes  of  services  and  expenses  related to general hospital based grant programs  for  the  period  April  first,  nineteen hundred ninety-four through June thirtieth, nineteen hundred ninety-six.   * NB Effective December 31, 2023   16-a. Pool administration, general. (a) If a general hospital fails to timely file a report with the department of funds due to a regional pool or   a   statewide  pool  established  pursuant  to  this  section,  the commissioner may estimate the amount due from  such  hospital  based  on available  financial  and statistical data and may collect in accordance with subdivision twenty of this section any amount  due  based  on  such estimate  as a deficiency in payments to such regional pool or statewide pool with interest and  penalties.  The  commissioner  shall  provide  a general  hospital with notice of any estimate of the amount due pursuant to this  paragraph  at  least  three  days  prior  to  collection  of  a deficiency  by the commissioner. Such notice shall contain the financial basis for the commissioner's estimate.   * (b)  Notwithstanding  any  inconsistent  provision  of  section  one hundred  twelve  or one hundred seventy-four of the state finance law or any  other  law,  at  the  discretion  of  the  commissioner   and   the commissioner of social services without a competitive bid or request for proposal  process,  regional  pool  and  statewide  pool  administration contracts in effect for rate year nineteen hundred ninety-three  may  be extended  for  administration  of  regional  pools  and  statewide pools established for rate years nineteen  hundred  ninety-four  and  nineteen hundred  ninety-five  and  nineteen  hundred  ninety-six  to  provide an uninterrupted continuation of services and may  be  amended  as  may  be necessary.   * NB Effective until December 31, 2023   * (b)  Notwithstanding  any  inconsistent  provision  of  section  one hundred twelve or one hundred seventy-four of the state finance  law  or  any   other   law,  at  the  discretion  of  the  commissioner  and  the commissioner of social services without a competitive bid or request for proposal  process,  regional  pool  and  statewide  pool  administration contracts  in  effect for rate year nineteen hundred ninety-three may be extended for  administration  of  regional  pools  and  statewide  pools established  for  rate  years  nineteen hundred ninety-four and nineteen hundred ninety-five and for the  rate  period  January  first,  nineteen hundred  ninety  six through June thirtieth, nineteen hundred ninety-six to provide an uninterrupted continuation of services and may be  amended as may be necessary.   * NB Effective December 31, 2023   17.  Bad  debt  and  charity  care  regional pool distributions. Funds accumulated in bad debt  and  charity  care  regional  pools,  including income  from  invested  funds, from the allowance specified in paragraph (c) of subdivision fourteen of this section and funds accumulated in bad debt and charity care regional pools,  including  income  from  invested funds,  from  the  transfer  of  funds  available  from the bad debt and charity care and capital statewide pool in accordance with paragraph (a) of subdivision nineteen of  this  section  shall  be  deposited  by  the commissioner  and  credited  to  a  special  revenue-other  fund  to  be established by the comptroller. To  the  extent  of  funds  appropriated therefor, funds shall be made available for distribution by or on behalf of  the  state,  as  payments under the state medical assistance program provided pursuant to title eleven of article five of the social services law, from bad debt and charity care regional pools  in  accordance  with the following methodology and sequence:  (a)   For   the   nineteen   hundred  eighty-eight,  nineteen  hundred eighty-nine and for that portion of the  nineteen  hundred  ninety  rate year  beginning  on  January  first  and  ending on June thirtieth, each eligible major public general hospital shall receive a  portion  of  its bad  debt  and charity care need equal to one hundred two percent of the result of the application  of  its  percentage  of  statewide  inpatient reimbursable  costs  excluding  costs  related  to  services provided to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare),  developed  on  the  basis  of  nineteen hundred eighty-five financial and statistical reports, to the total of all  regional  pools. For  that  portion of the nineteen hundred ninety rate year beginning on July first and ending on December thirty-first and in  the  annual  rate years  beginning on or after January first, nineteen hundred ninety-one, each eligible major public general hospital shall receive a  portion  of its  bad  debt and charity care need equal to one hundred ten percent of the result of the application of its percentage of  statewide  inpatient reimbursable  costs  excluding  costs  related  to  services provided to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare),  developed  on  the  basis  of  nineteen hundred eighty-five financial and statistical reports, to the total of all regional pools.  (b) (i) Funds remaining in the regional pools  after  distribution  in accordance  with  paragraph (a) of this subdivision shall be distributed to  voluntary  non-profit,  private  proprietary  and   public   general hospitals,  other  than  major public general hospitals, on the basis of each hospital's targeted need share. For the rate year beginning January first, nineteen hundred eighty-eight, an individual hospital's  targeted need  share shall be defined as the relationship between each hospital's nineteen  hundred  eighty-six  nominal  payment  amount  as  defined  in subparagraph  (i)  of  paragraph  (c)  of  subdivision  fourteen of this section to the nineteen hundred eighty-six nominal payment  amounts  for all  hospitals  in the region other than major public general hospitals. For annual rate years beginning on  or  after  January  first,  nineteen  hundred  eighty-nine,  the base need shall be the calendar year which is two years prior to the rate year. The amount of funds to be  distributed in  accordance with this paragraph and paragraph (a) of this subdivision shall be limited to the amount of funds accumulated in the pools.  (ii)  Notwithstanding  any  inconsistent  provision  of  this section, commencing April first, nineteen hundred ninety-five funds remaining  in the  regional  pools after distribution in accordance with paragraph (a) of this subdivision shall be aggregated on a statewide basis and treated as  a  common  pool  for  statewide  distributions  and  distributed  to voluntary  non-profit, private proprietary and public general hospitals, other than  major  public  general  hospitals,  on  the  basis  of  each hospital's  targeted need share defined as the relationship between each hospital's base year nominal payment amount as defined  in  subparagraph (i) of paragraph (c) of subdivision fourteen of this section to the base year  nominal  payment  amounts  for  all hospitals statewide other than major public general hospitals.  (d) The  department  may  provide  for  interim  payments  to  general hospitals  of  funds  available  for  distribution  from  regional pools pursuant to  this  subdivision,  subject  to  reasonable  retainage  for adjustments,  subsequently  reconciled  to  amounts  due  determined  in accordance with this subdivision.  (e) Notwithstanding any inconsistent provision of this section, in the event  funds  available  pursuant  to  paragraph  (b-1)  of  subdivision nineteen  of  this  section for programs to provide health care coverage for  uninsured  or  underinsured  children  are  inadequate  to  provide coverage  to  all eligible children for whom application for coverage is made in a rate period, such additional amounts not to exceed twenty-five million dollars for nineteen hundred ninety-four as shall  be  necessary to  provide such coverage shall be reserved by the commissioner from the amount to be available in bad debt and charity care regional  pools  for such  rate  period  for  additional  distributions to such programs. Ten million dollars of the amount reserved for nineteen hundred  ninety-four shall  not  result  in  a decrease to disproportionate share payments to hospitals.   18. Bad debt and charity care  and  capital  statewide  pool  funding. * The  commissioner shall create a bad debt and charity care and capital statewide pool which shall be funded by a transfer of  funds,  which  is hereby  authorized,  for  the  period  January  first,  nineteen hundred ninety-five through December thirty-first, nineteen hundred ninety-five, the period January  first,  nineteen  hundred  ninety-six  through  June thirtieth,  nineteen  hundred  ninety-six  and  the  period  July first, nineteen hundred  ninety-six  through  December  thirty-first,  nineteen hundred  ninety-six equal to seven million five hundred thousand dollars for the nineteen hundred ninety-five period, three million seven hundred fifty  thousand  dollars  for  the  January  first,   nineteen   hundred ninety-six  through  June  thirtieth, nineteen hundred ninety-six period and three million seven hundred fifty  thousand  dollars  for  the  July first,   nineteen  hundred  ninety-six  through  December  thirty-first, nineteen hundred ninety-six period to be submitted to a statewide  pool, as   designated  by  the  commissioner,  from  the  medical  malpractice insurance association pursuant to section  five  thousand  five  hundred sixteen-c  of the insurance law and through an assessment which shall be charged to general hospitals. In the event that the transfers  of  funds authorized  by  section  five  thousand  five  hundred  sixteen-c of the insurance  law  do  not  occur  by  January  first,   nineteen   hundred ninety-five,  January  first,  nineteen  hundred  ninety-six  and August first, nineteen hundred ninety-six respectively,  the  commissioner  for each  period  for  which  such  transfer  from  the  medical malpractice  insurance association has not occurred shall transfer seven million five hundred thousand dollars for the nineteen  hundred  ninety-five  period, three  million  seven  hundred  fifty  thousand  dollars for the January first,  nineteen  hundred  ninety-six  through  June thirtieth, nineteen hundred ninety-six period and three million seven hundred fifty thousand dollars for the July first, nineteen hundred ninety-six through December thirty-first,  nineteen  hundred  ninety-six  period  from  regional  or statewide  pool  reserves for pools established pursuant to this section and section twenty-eight hundred eight-c or twenty-eight hundred seven-a of this article to the bad debt and charity care and  capitol  statewide pool  established pursuant to this subdivision. Such assessment shall be submitted to a statewide pool as  designated  by  the  commissioner  and distributed  on a monthly basis in accordance with subdivision twenty of this section. The assessment shall be:   * NB Effective until December 31, 2023   * The commissioner shall create  a  bad  debt  and  charity  care  and capital  statewide  pool  which  shall be funded by a transfer of funds, which is hereby authorized,  for  the  period  January  first,  nineteen hundred  ninety-five  through  December  thirty-first,  nineteen hundred ninety-five and the period January first,  nineteen  hundred  ninety-six through  June  thirtieth,  nineteen  hundred  ninety-six  equal to seven million  five  hundred  thousand  dollars  for  the   nineteen   hundred ninety-five  period  and  three  million  seven  hundred  fifty thousand dollars for the January first, nineteen hundred ninety-six through  June thirtieth,  nineteen  hundred  ninety-six  period  to  be submitted to a statewide pool, as designated by  the  commissioner,  from  the  medical malpractice insurance association pursuant to section five thousand five hundred  sixteen-c  of the insurance law and through an assessment which shall be charged to general hospitals. In the event that  the  transfers of  funds  authorized by section five thousand five hundred sixteen-c of the insurance law do  not  occur  by  January  first,  nineteen  hundred ninety-five  and January first nineteen hundred ninety-six respectively, the commissioner for each  period  for  which  such  transfer  from  the medical   malpractice  insurance  association  has  not  occurred  shall transfer seven million five hundred thousand dollars  for  the  nineteen hundred  ninety-five  period  and  three  million  seven  hundred  fifty thousand dollars for the  January  first,  nineteen  hundred  ninety-six through June thirtieth, nineteen hundred ninety-six period from regional or  statewide  pool  reserves  for  pools  established  pursuant to this section and section twenty-eight hundred eight-c or twenty-eight hundred seven-a of this article to the bad debt and  charity  care  and  capital statewide pool established pursuant to this subdivision. Such assessment shall be submitted to a statewide pool as designated by the commissioner and distributed on a monthly basis in accordance with subdivision twenty of this section. The assessment shall be:   * NB Effective December 31, 2023   * (a)  one  and  seventy-five  thousandths  percent  of  each  general hospital's  gross  revenue  received  for  inpatient  hospital  services provided  during the period January first, nineteen hundred eighty-eight through December thirty-first, nineteen hundred  eighty-eight;  one  and five  hundredths  percent  of  each  general  hospital's  gross  revenue received for inpatient hospital  services  provided  during  the  period January   first,   nineteen   hundred   eighty-nine   through   December thirty-first, nineteen hundred eighty-nine;  and  one  percent  of  each general   hospital's  gross  revenue  received  for  inpatient  hospital services provided during annual periods beginning on  or  after  January first,  nineteen  hundred ninety through December thirty-first, nineteen hundred ninety-nine and on or after January first, two thousand,    * NB Effective until December 31, 2023   * (a)  one  and  seventy-five  thousandths  percent  of  each  general hospital's  gross  revenue  received  for  inpatient  hospital  services provided  during the period January first, nineteen hundred eighty-eight through December thirty-first, nineteen hundred  eighty-eight;  one  and five  hundredths  percent  of  each  general  hospital's  gross  revenue received for inpatient hospital  services  provided  during  the  period January   first,   nineteen   hundred   eighty-nine   through   December thirty-first, nineteen hundred eighty-nine;  and  one  percent  of  each general   hospital's  gross  revenue  received  for  inpatient  hospital services provided during annual periods beginning on  or  after  January first,  nineteen  hundred ninety through December thirty-first, nineteen hundred ninety-nine,   * NB Effective and expires December 31, 2023   * (a)  one  and  seventy-five  thousandths  percent  of  each  general hospital's  gross  revenue  received  for  inpatient  hospital  services provided during the period January first, nineteen hundred  eighty-eight through  December  thirty-first,  nineteen hundred eighty-eight; one and five  hundredths  percent  of  each  general  hospital's  gross  revenue received  for  inpatient  hospital  services  provided during the period January   first,   nineteen   hundred   eighty-nine   through   December thirty-first,  nineteen  hundred  eighty-nine;  and  one percent of each general  hospital's  gross  revenue  received  for  inpatient   hospital services  provided  during  annual  rate  periods  beginning on or after January first, nineteen hundred ninety,   * NB Effective December 31, 2023   * (b) provided, however, subject to the provisions of paragraph (e) of this subdivision there shall be no assessment  against  those  voluntary non-profit  and  private proprietary general hospitals which qualify for distributions made in  accordance  with  paragraph  (c)  of  subdivision nineteen  of  this  section, or for the annual assessment period January first, nineteen  hundred  ninety-seven  through  December  thirty-first, nineteen  hundred ninety-seven which qualified for distributions made in accordance with paragraph (c) of subdivision nineteen of this section as of December thirty-first, nineteen hundred ninety-five, and   * NB Effective until December 31, 2023   * (b) provided, however, subject to the provisions of paragraph (e) of this subdivision there shall be no assessment  against  those  voluntary non-profit  and  private proprietary general hospitals which qualify for distributions made in  accordance  with  paragraph  (c)  of  subdivision nineteen of this section, and   * NB Effective December 31, 2023   * (c)   provided  further,  however,  subject  to  the  provisions  of paragraph (e) of this subdivision the assessment against those voluntary non-profit and private proprietary general hospitals which qualified for distributions made in  accordance  with  paragraph  (c)  of  subdivision nineteen  of  this section as of December thirty-first, nineteen hundred ninety-five shall  for  the  annual  assessment  period  January  first, nineteen  hundred  ninety-eight  through December thirty-first, nineteen hundred ninety-eight be abated in the amount of  three-quarters  of  one percent  of  gross revenue received and for the annual assessment period January   first,   nineteen   hundred   ninety-nine   through   December thirty-first,  nineteen  hundred  ninety-nine be abated in the amount of one-quarter of one percent of gross revenue received.   * NB Effective until December 31, 2023   * (c)  provided  further,  however,  subject  to  the  provisions   of paragraph (e) of this subdivision the assessment against those voluntary non-profit and private proprietary general hospitals which qualified for  distributions  made  in  accordance  with  paragraph  (b) of subdivision sixteen of section twenty-eight hundred seven-a of this  article  during the   nineteen   hundred  eighty-seven  rate  period  or  qualified  for distributions  made  in  accordance  with  paragraph  (c) of subdivision nineteen of this section during a rate period or rate periods but  which do  not  continue  to  qualify for distributions made in accordance with paragraph (c) of subdivision nineteen of  this  section  during  a  rate period  or  rate periods shall for the initial rate period in which such general hospital does not continue to qualify for distributions made  in accordance with paragraph (c) of subdivision nineteen of this section be abated  in  the  amount  of  two-thirds  of one percent of gross revenue received and for the next succeeding annual rate period be abated in the amount of one-third of one percent of gross revenue received.   * NB Effective December 31, 2023   * (d) Gross revenue received shall mean all moneys received for or  on account  of  inpatient hospital service, provided, however, that subject to the provisions of paragraph (e) of  this  subdivision  gross  revenue received  shall not include distributions from bad debt and charity care regional pools, health care services pools, bad debt  and  charity  care for  financially  distressed  hospitals statewide pools and bad debt and charity care and capital statewide pools created in accordance with this section or distributions from funds allocated in accordance with section twenty-eight hundred seven-l, twenty-eight hundred seven-k, twenty-eight hundred seven-v or twenty-eight hundred  seven-w  of  this  article  and shall  not include the components of rates of payment or charges related to the allowances provided in  accordance  with  subdivisions  fourteen, fourteen-b  and  fourteen-c  of this section, the adjustment provided in accordance with subdivision fourteen-a of this section,  the  adjustment provided  in accordance with subdivision fourteen-d of this section, the adjustment  for  health  maintenance  organization  reimbursement  rates provided  in  accordance  with former subdivision two-a of this section, payments made pursuant to paragraph (i) of  subdivision  thirty-five  of this  section  or,  if  effective, the adjustment provided in accordance with subdivision fifteen of this section,  the  adjustment  provided  in accordance with section eighteen of chapter two hundred sixty-six of the laws  of  nineteen  hundred eighty-six as amended, revenue received from physician practice  or  faculty  practice  plan  discrete  billings  for private   practicing   physician   services,  revenue  from  affiliation agreements or contracts with public hospitals for the delivery of health care  services  at  such   public   hospitals,   revenue   received   as disproportionate  share  hospital  payments  in  accordance  with  title nineteen of the federal social security act, or revenue from  government deficit  financing,  provided,  however,  that funds received as medical assistance  payments  which  include  state  share  amounts   authorized pursuant  to  section  twenty-eight hundred seven-v of this article that are not disproportionate  share  hospital  payments  shall  be  included within the meaning of gross revenue for purposes of this subdivision.   * NB Effective until December 31, 2023   * (d)  Gross revenue received shall mean all moneys received for or on account of inpatient hospital service, provided, however,  that  subject to  the  provisions  of  paragraph (e) of this subdivision gross revenue received shall not include distributions from bad debt and charity  care regional  pools,  health  care services pools, bad debt and charity care for financially distressed hospitals statewide pools and  bad  debt  and charity care and capital statewide pools created in accordance with this section  and  shall  not  include  the components of rates of payment or charges  related  to  the  allowances  provided   in   accordance   with subdivisions  fourteen,  fourteen-b  and fourteen-c of this section, the  adjustment provided in accordance with subdivision  fourteen-a  of  this section,   the   adjustment  provided  in  accordance  with  subdivision fourteen-d of  this  section,  the  adjustment  for  health  maintenance organization reimbursement rates provided in accordance with subdivision two-a  of  this  section,  or,  if effective, the adjustment provided in accordance with subdivision fifteen of this section  or  the  adjustment provided  in  accordance  with  section  eighteen of chapter two hundred sixty-six of the laws of nineteen hundred eighty-six as amended.   * NB Effective December 31, 2023  (e) Each exclusion of hospitals or sources of gross  revenue  received from  the  assessments  effective  on  or  after October first, nineteen hundred ninety-two established pursuant to  this  subdivision  shall  be contingent  upon either: (i) qualification of the assessments for waiver pursuant to federal law and regulation; or, (ii) consistent with federal law and regulation, not requiring a  waiver  by  the  secretary  of  the department  of  health  and human services related to such exclusion; in order for the assessments under  this  section  to  be  qualified  as  a broad-based  health  care  related  tax  for  purposes  of  the revenues received by the state pursuant  to  the  assessments  not  reducing  the amount  expended  by  the  state  as  medical assistance for purposes of federal financial participation.  The  commissioner  shall  collect  the assessments  relying  on such exclusions, pending any contrary action by the secretary of the department of health and  human  services.  In  the event  the  secretary  of  the  department  of health and human services determines that the assessments do not so  qualify  based  on  any  such exclusion, then the exclusion shall be deemed to have been null and void as  of  October  first, nineteen hundred ninety-two and the commissioner shall collect any retroactive amount due as a result,  without  interest or  penalty provided the hospital pays the retroactive amount due within ninety days of notice from the commissioner to  the  hospital  that  the exclusion  is  null  and  void. Interest and penalties shall be measured from the due date of ninety days following notice from the  commissioner to the hospital.  (f) Payments of assessments and allowances required to be submitted by general hospitals pursuant to this subdivision and subdivisions fourteen and  fourteen-b  of this section and paragraph (a) of subdivision two of section twenty-eight hundred seven-d of this article shall be subject to audit by the commissioner for a period of six years following the  close of  the  calendar  year in which such payments are due, after which such payments shall be deemed final and not subject to further adjustment  or reconciliation,  including through offset adjustments or reconciliations made by general hospitals with regard to subsequent payments,  provided, however,  that  nothing  herein  shall  be  construed  as precluding the commissioner from  pursuing  collection  of  any  such  assessments  and allowances  which  are  identified  as  delinquent  within such six year period, or which are identified as delinquent as a result  of  an  audit commenced within such six year audit period, or from conducting an audit of  any  adjustment  or reconciliation made by a general hospital within such six year period, or from conducting an audit of payments made prior to such six year period which are found to be commingled  with  payments which  are  otherwise  subject to timely audit pursuant to this section. General hospitals which, in the course of such an audit, fail to produce data or documentation requested in furtherance of such an audit,  within thirty days of such request may be assessed a civil penalty of up to ten thousand  dollars  for  each  such failure, provided, however, that such civil penalty shall not be imposed if  the  hospital  demonstrates  good cause  for such failure. The imposition of such civil penalties shall be subject to the provisions of section twelve-a of this chapter.  (g) If a general hospital  fails  to  produce  data  or  documentation requested  in furtherance of an audit for a month to which an assessment applies, the commissioner may estimate, based on available financial and statistical data as determined by the commissioner, the amount  due  for such  month. If the impact of exemptions permitted pursuant to paragraph (d) of  this  subdivision  cannot  be  determined  from  such  available financial   and  statistical  data  the  estimated  amount  due  may  be calculated on the  basis  of  the  general  hospital's  aggregate  gross inpatient  revenue  amount,  as determined from such available financial and statistical data for the year subject to  audit.  Estimated  amounts due  pursuant  to  this  paragraph  shall  be paid by a general hospital within sixty days or within such other time period as agreed to  by  the commissioner  and  the  facility. Thereafter the commissioner shall take all necessary steps to collect amounts owed pursuant to this  paragraph, including  by  offsetting,  or  by  directing  the  state comptroller to offset,  such  amounts  due  from  any  other  payments  made  by  state governmental  agencies to the general hospital pursuant to this article. Interest  and  penalties  shall  be  applied  to  such  amounts  due  in accordance with the provisions of paragraph (c) of subdivision twenty of this section.  (h)  The  commissioner  shall  take  all  necessary  steps  to collect delinquent amounts owed  pursuant  to  this  subdivision,  including  by recoupment  or  offsetting,  or  by  directing  the state comptroller to offset,  such  amounts  due  from  any  other  payments  made  by  state governmental  agencies to the general hospital pursuant to this article. Interest  and  penalties  shall  be  applied  to  such  amounts  due  in accordance with the provisions of paragraph (c) of subdivision twenty of this section. Delinquent amounts which have been referred for recoupment or offset pursuant to this paragraph, or which have been referred to the office of the attorney general for collection, shall be deemed final and not  subject  to  further revision or reconciliation by the commissioner based on any additional reports or other information  submitted  by  the hospital,  provided,  however,  that  such  delinquencies  shall  not be referred for such recoupment or for such collection based  on  estimated amounts  unless  the  hospital has received written notification of such delinquencies and has been given no less than thirty days  in  which  to submit delinquent reports.  (i)  The commissioner may enter into agreements with general hospitals subject to this subdivision, in regard to which audit findings or  prior settlements  have  been made pursuant to this subdivision, extending and applying such audit findings or prior settlements or a portion  thereof, in  settlement  and  satisfaction  of  potential  audit  liabilities for subsequent un-audited periods. The  commissioner  may  reduce  or  waive payment   of   interest  and  penalties  otherwise  applicable  to  such subsequent un-audited periods when such amounts due as a result of  such agreement, other than reduced or waived penalties and interest, are paid in  full to the commissioner or the commissioner's designee within sixty days of execution of such agreement by all parties to the agreement. Any payments made pursuant to agreements entered  into  in  accordance  with this  paragraph  shall  be  deemed  to  be  in  full satisfaction of any liability  arising  under  this  subdivision,  as  referenced  in   such agreements  and  for  the  time  periods  covered  by  such  agreements, provided, however, that the commissioner may  audit  future  retroactive adjustments  to payments made for such periods based on reports filed by hospitals subsequent to such agreements.   19. Bad debt and charity care and capital statewide pool distribution. *  Funds accumulated in the statewide pool  created  by  the  assessment authorized  in  accordance with subdivision eighteen of this section for  periods through  December  thirty-first,  nineteen  hundred  ninety-six, including  income  from invested funds, shall be distributed or retained in accordance with the following sequence:   * NB Effective until December 31, 2023   * Funds  accumulated  in  the statewide pool created by the assessment authorized in accordance with  subdivision  eighteen  of  this  section, including  income  from invested funds, shall be distributed or retained in accordance with the following sequence:   * NB Effective December 31, 2023  (a) Funds shall be distributed by the commissioner  to  bad  debt  and charity  care regional pools established pursuant to subdivision sixteen of this section to provide additional funds for distribution  from  such bad  debt and charity care regional pools in accordance with subdivision seventeen of this section equal to the amount computed as the difference between the amount that would be available in such regional pools  based on  a  statewide determination of financial resources to be committed to regional pools  in  each  year  in  accordance  with  paragraph  (c)  of subdivision  fourteen  of  this  section  based upon a percentage factor equal to five and ninety-three hundredths percent and the amount  to  be available  in  such regional pools based on a statewide determination of financial resources to be committed to regional pools in  each  year  in accordance  with  paragraph  (c) of subdivision fourteen of this section based upon a percentage factor equal to five and forty-eight  hundredths percent.   * (b)  An  amount  not  to  exceed  seventeen  million  dollars  on an annualized basis from  the  assessment  through  December  thirty-first, nineteen  hundred  ninety-six  may  annually  be  placed  in a statewide account in accordance with rules and regulations adopted by the  council and  approved  by the commissioner for the purpose of securing financing of capital improvement projects for  general  hospitals  qualifying  for distributions made in accordance with paragraph (c) of this subdivision. Any  reserved  funds  available  on  September  first,  nineteen hundred ninety-seven and not obligated, in accordance  with  section  twelve  of chapter  nine  hundred  thirty-four  of  the  laws  of  nineteen hundred eighty-five as amended, for the purpose of securing financing of capital improvement projects for general hospitals and any reserved  funds  that thereafter  become  available may be transferred by the commissioner, in consultation  with  the  director  of  the  budget  and  the   dormitory authority,   to  the  health  facility  restructuring  pool  established pursuant to section twenty-eight hundred fifteen of this article  or  to the  general hospital indigent care pool established pursuant to section twenty-eight hundred seven-k of this article.   * NB Effective until December 31, 2023   * (b) An amount not to exceed seventeen million dollars  may  annually be   placed  in  a  statewide  account  in  accordance  with  rules  and regulations adopted by the council and approved by the commissioner  for the  purpose  of  securing financing of capital improvement projects for general hospitals qualifying for distributions made in  accordance  with paragraph (c) of this subdivision.   * NB Effective December 31, 2023   * (b-1)  An  amount  equal to: twenty million dollars annually for the period January  first,  nineteen  hundred  ninety-one  through  December thirty-first,  nineteen hundred ninety-three; thirty million dollars for the period January first, nineteen hundred ninety-four through  December thirty-first,  nineteen  hundred  ninety-four; thirty-seven million five hundred thousand dollars for the period January first, nineteen  hundred ninety-five through December thirty-first, nineteen hundred ninety-five; eighteen  million  seven  hundred  fifty thousand dollars for the period  January first,  nineteen  hundred  ninety-six  through  June  thirtieth, nineteen  hundred  ninety-six;  and eighteen million seven hundred fifty thousand dollars for the period July first, nineteen hundred  ninety-six through   December   thirty-first,  nineteen  hundred  ninety-six  shall annually  be  reserved  and  accumulated  from  year  to  year  by   the commissioner  for  distributions  to  programs  to  provide  health care coverage for uninsured or underinsured children. Such accumulated  funds shall  not  be used for any other purpose other than those authorized in section twenty-five hundred ten and twenty-five hundred eleven  of  this chapter.  If  on  March thirty-first, nineteen hundred ninety-eight, any funds accumulated during the  period  January  first,  nineteen  hundred ninety-one  through December thirty-first, nineteen hundred ninety-seven are unused  or  uncommitted  for  such  distributions,  such  unused  or uncommitted  funds  shall be immediately transferred by the commissioner to the health care initiatives pool established by the  commissioner  to provide  additional funds for distribution to programs to provide health care  coverage  for  uninsured  or  underinsured  children  pursuant  to sections  twenty-five hundred ten and twenty-five hundred eleven of this chapter. For cash  flow  purposes,  the  commissioner  may  borrow  from regional  or  statewide  pool reserves for pools established pursuant to this section such funds as shall be necessary not to exceed  the  amount authorized to be reserved annually to meet premium requirements pursuant to  sections  twenty-five  hundred ten and twenty-five hundred eleven of this chapter for a rate year and shall  refund  such  moneys  when  pool funds become available pursuant to this paragraph for such rate year.   * NB Effective until December 31, 2023   * (b-1)  An  amount  equal to: twenty million dollars annually for the period January  first,  nineteen  hundred  ninety-one  through  December thirty-first,  nineteen hundred ninety-three; thirty million dollars for the period January first, nineteen hundred ninety-four through  December thirty-first,  nineteen  hundred  ninety-four; thirty-seven million five hundred thousand dollars for the period January first, nineteen  hundred ninety-five through December thirty-first, nineteen hundred ninety-five; and eighteen million seven hundred fifty thousand dollars for the period January  first,  nineteen  hundred  ninety-six  through  June thirtieth, nineteen hundred ninety-six shall annually be reserved  and  accumulated from  year  to year by the commissioner for distributions to programs to provide health care coverage for  uninsured  or  underinsured  children. Such  accumulated  funds  shall  not be used for any other purpose other than those authorized in section twenty-five hundred ten and twenty-five hundred eleven of this chapter.  If  on  September  thirtieth,  nineteen hundred  ninety-seven,  any  funds accumulated during the period January first, nineteen hundred  ninety-one  through  June  thirtieth,  nineteen hundred  ninety-six  are  unused  or uncommitted for such distributions, such unused or uncommitted funds shall be immediately transferred by the commissioner to bad debt and charity  care  regional  pools  established pursuant  to  subdivision  sixteen of this section to provide additional funds for distribution from such bad  debt  and  charity  care  regional pools in accordance with subdivision seventeen of this section. For cash flow  purposes,  the  commissioner may borrow from regional or statewide pool reserves for pools established pursuant to this section such  funds as shall be necessary not to exceed the amount authorized to be reserved annually  to  meet premium requirements pursuant to sections twenty-five hundred ten and twenty-five hundred eleven of this chapter  for  a  rate year  and  shall  refund  such  moneys  when pool funds become available pursuant to this paragraph for such rate year.   * NB Effective December 31, 2023  (b-2) Funds available for distribution in accordance  with  paragraphs (c)  and  (d) of this subdivision shall be deposited by the commissioner and credited to a special revenue-other fund to be  established  by  the comptroller.  To  the extent of funds appropriated therefor, funds shall be  made  available  for  distributions by or on behalf of the state, as payments under the state medical assistance program provided pursuant to title eleven of article five of the social services  law  from  the  bad debt  and charity care and capital statewide pool pursuant to paragraphs (c) and (d) of this subdivision.  (c)  Funds  shall  be  made  available  on  a  statewide   basis   for distribution   by   the   commissioner  in  accordance  with  rules  and regulations adopted by the council and approved by the  commissioner  to assist  voluntary  non-profit  and private proprietary general hospitals experiencing severe fiscal hardship because of insufficient resources to finance losses resulting from bad debts and the costs of  charity  care. Amounts  to  be distributed for bad debt and charity care purposes shall be determined after consideration of  amounts  to  be  distributed  from regional  pools in accordance with subdivision seventeen of this section and shall result in up to one hundred percent as  defined  in  paragraph (b)  of  subdivision  fourteen  of this section being financed for these general hospitals.  (d)  Funds  shall  be  made  available  on  a  statewide   basis   for distribution   by   the   commissioner  in  accordance  with  rules  and regulations adopted by the council and approved by the  commissioner  to assist  voluntary  non-profit  and private proprietary general hospitals which qualified for distributions made in accordance with paragraph  (b) of  subdivision  sixteen of section twenty-eight hundred seven-a of this article  during  the  nineteen  hundred  eighty-seven  rate  period   or qualified  for  distributions  made  in accordance with paragraph (c) of this subdivision during a rate period or rate periods but which  do  not continue  to qualify for distributions made in accordance with paragraph (c) of this subdivision during a rate period or rate periods. Amounts to be distributed to a general hospital pursuant to this paragraph for  the initial  rate period in which such general hospital does not continue to qualify for distributions made in accordance with paragraph (c) of  this subdivision  shall  be  two-thirds  of  the amount such general hospital would have received in accordance with paragraph (c) of this subdivision for such initial rate  period  if  the  hospital  had  continued  to  be eligible  for  such distribution and for the next succeeding annual rate period one-third of the amount such general hospital would have received in accordance with paragraph (c) of this subdivision for such succeeding rate period.  (e) There shall be set  aside  within  a  transition  account  in  the statewide pool, from accumulated funds, from the total allocation to the bad  debt  and charity care and capital statewide pool of the assessment of one and seventy-five thousandths percent of gross revenue received in accordance with paragraph (a) of subdivision eighteen  of  this  section for   the   rate  period  commencing  January  first,  nineteen  hundred eighty-eight and the assessment of one and five  hundredths  percent  of gross  revenue  received in accordance with paragraph (a) of subdivision eighteen of this section for the rate period commencing  January  first, nineteen hundred eighty-nine an amount equal to seventy-five thousandths of  one  percent  of  gross  revenue received and five hundredths of one percent of gross revenue received  respectively  to  be  distributed  to voluntary  non-profit,  private proprietary and public general hospitals receiving less bad debt and charity care funds under the  provisions  of this  section  than  if  the  provisions of section twenty-eight hundred seven-a of this article had applied using the same  base  year  need  as  calculated  in  accordance  with  subdivision  fourteen of this section. Rules for such distribution shall be those adopted by  the  council  and approved by the commissioner.  (f)  Any  balance  in  the  statewide  pool  shall  be  distributed in accordance with the following:  (i) Fifty percent of the balance shall  be  reserved  and  accumulated from  year  to  year  by  the commissioner for distributions to regional pilot projects to  provide  health  care  coverage  under  insurance  or equivalent  mechanisms  for  uninsured  or  underinsured individuals and families and to provide health care coverage for  catastrophic  expenses provided  legislation is enacted before July fifteenth, nineteen hundred eighty-eight authorizing such regional pilot projects and  including  an authorization  for  such  regional  pilot  projects, notwithstanding any inconsistent  provision  of  law,  to  negotiate  special  payment  rate methodologies with general hospitals for inpatient hospital services.  (ii)  * The  remaining  balance shall be reserved and accumulated from year  to  year  by  the  commissioner  for  priority  distributions   in accordance  with  rules  and  regulations  adopted  by  the  council and approved by  the  commissioner:  (A)  to  assist  general  hospitals  in offsetting  losses  from  bad  debt  and  the  costs  of charity care in providing existing or expanded priority health services to the medically indigent or medically underserved in urban and  rural  areas  including, but  not  limited to, services for pregnant women, services for children under the age of six, and services related to acquired immune deficiency syndrome; (B) for quality  assurance  demonstration  projects;  (C)  for severity  of  illness  measurement  demonstration projects; (D) for cost analyses and evaluations of  health  care  provider  services;  (E)  for quality improvement program grants and contracts pursuant to subdivision fifteen  of  section  two  hundred six of this chapter and department of health administrative costs related thereto; and (F) for initiatives  to improve  public  health  and  to  expand the availability of health care services.   * NB Effective until December 31, 2023   * The remaining balance shall be reserved and accumulated from year to year by the commissioner for priority distributions in  accordance  with rules  and  regulations  adopted  by  the  council  and  approved by the commissioner: (A) to assist general hospitals in offsetting losses  from bad debt and the costs of charity care in providing existing or expanded priority   health  services  to  the  medically  indigent  or  medically underserved in urban and rural areas  including,  but  not  limited  to, services for pregnant women, services for children under the age of six, and  services  related  to  acquired immune deficiency syndrome; (B) for quality assurance demonstration projects; (C) for  severity  of  illness measurement   demonstration   projects;   (D)   for  cost  analyses  and evaluations of health  care  provider  services;  and  (E)  for  quality improvement program grants and contracts pursuant to subdivision fifteen of  section  two  hundred  six  of this chapter and department of health administrative costs related thereto.   * NB Effective December 31, 2023   Notwithstanding any provision of law to the contrary,  a  sum  not  to exceed  three million five hundred thousand dollars from funds available for distribution pursuant to this  subparagraph  may  be  allocated  and distributed  to  regional pilot projects to provide health care coverage under insurance or equivalent mechanisms for uninsured  or  underinsured individuals  and families pursuant to chapter seven hundred three of the laws of nineteen hundred eighty-eight.   Notwithstanding any inconsistent  provision  of  section  one  hundred twelve or one hundred seventy-four of the state finance law or any other  law,  funds available for distribution pursuant to this subparagraph may be allocated and distributed without a competitive bid  or  request  for proposal process.  (iii)  Any unused funds from the allocations provided for in paragraph (b) and paragraph (e) of this subdivision and subparagraph (i)  of  this paragraph  and  any  funds  contingently  allocated  to  regional  pilot projects pursuant to subparagraph (i) of this paragraph  if  authorizing legislation  is  not  enacted  as required by such subparagraph shall be reallocated for use in accordance with the  provisions  of  subparagraph (ii) of this paragraph.  (iv)  Notwithstanding  any inconsistent provision of this section, the commissioner shall enter into  agreements  with  one  or  more  persons, not-for-profit  corporations, or other organizations, other than a state employee, official  or  agency,  for  the  purposes  of  an  independent evaluation  of  the  implementation  and  effectiveness  of primary care initiatives, including preferred  primary  care  provider  designations, applicable  to  general  hospitals, diagnostic and treatment centers and participating  practitioners  and  may  allocate  and  distribute  funds otherwise  available  for  distribution  in accordance with subparagraph (ii) of this paragraph for the costs of such evaluation. The  evaluation shall assess factors including but not limited to:  (A)  the  overall effect of such primary care initiatives on access to and utilization of health care services;  (B) the extent to which such  initiatives  have  fostered  cooperative working relationships between various providers of health care services;  (C)  the  impact  of  such  initiatives  on  the  cost  of health care services.   An initial evaluation pursuant to this subparagraph shall be submitted to the governor and the legislature on or before April  first,  nineteen hundred  ninety-two and a further evaluation shall be submitted by April first, nineteen hundred ninety-three.   * 19-a. Health care services allowance  statewide  pool  distribution. Funds  accumulated  in  the  statewide  pool  created  by  the allowance authorized in accordance with subparagraphs (ii) and (iii) of  paragraph (a)  of  subdivision  fourteen-b  of this section, including income from invested funds, shall be distributed or retained in accordance with  the following:  (a)  Funds  shall  be  transferred  to  primary  health  care services regional pools created by the  commissioner,  and  shall  be  available, including  income  from  invested funds, for distributions in accordance with section twenty-eight hundred seven-bb of this article.  Such  funds shall  be  transferred  to  each regional pool so that the regional pool receives,  for  the  rate  periods  January  first,   nineteen   hundred ninety-four  through December thirty-first, nineteen hundred ninety-four fifty-one and  five-tenths  percent,  January  first,  nineteen  hundred ninety-five  through December thirty-first, nineteen hundred ninety-five forty-nine and six-tenths percent, and January first,  nineteen  hundred ninety-six  through  December  thirty-first, nineteen hundred ninety-six forty-nine and six-tenths percent of the total funds to  be  accumulated in  the  statewide  pool from the allowance submitted by or on behalf of hospitals in that region. Such regions shall be  those  established  for purposes of section two thousand nine hundred four-b of this chapter.  (b) A fixed percentage of the total funds accumulated in the statewide pool,  including  income  from  invested  funds,  shall be available for primary care education and training. For the rate periods January first, nineteen hundred ninety-four  through  December  thirty-first,  nineteen hundred  ninety-four,  such percentage shall be twenty-two and one-tenth percent,  and  January  first,  nineteen  hundred  ninety-five   through  December  thirty-first,  nineteen  hundred  ninety-five, such percentage shall be twenty and four-tenths percent,  and  January  first,  nineteen hundred  ninety-six  through  December  thirty-first,  nineteen  hundred ninety-six  such  percentage  shall  be  twenty and four-tenths percent. Funds shall be available for distributions as follows:  (i) up to four million  dollars  annually  plus  income  thereon  from invested  funds  shall  be set aside and reserved from accumulated funds and may be accumulated for the following year for  distribution  by  the commissioner   for  primary  care  undergraduate  medical  education  in accordance with section nine hundred two of this chapter;  (ii) up to four million dollars  annually  plus  income  thereon  from invested  funds  shall  be set aside and reserved from accumulated funds and may be accumulated for the following year for  distribution  by  the commissioner  for  the  primary care physician loan repayment program in accordance with section nine hundred three of this chapter;  (iii) up to two million dollars  annually  plus  income  thereon  from invested  funds  shall  be set aside and reserved from accumulated funds and may be accumulated for the following year for  distribution  by  the commissioner  for  the  primary care practitioner scholarship program in accordance with section nine hundred four of this chapter;  (iv) up to two million  dollars  annually  plus  income  thereon  from invested  funds  shall  be set aside and reserved from accumulated funds and may be accumulated for the following year for  distribution  by  the commissioner  for  the  primary  care  practitioner education program in accordance with section nine hundred five of this chapter;  (v) the balance remaining annually plus income thereon  from  invested funds  shall be set aside and reserved from accumulated funds and may be accumulated from year to year for distributions by the commissioner  for health  care  development in accordance with section nine hundred six of this chapter; and  (vi) provided, however,  that  the  commissioner  in  the  absence  of qualified   recipients  within  a  category  may  reallocate  any  funds remaining or unallocated within such a category for distribution by  the commissioner  for  the  primary care practitioner scholarship program in accordance with section nine  hundred  four  of  this  chapter  and  the primary  care  practitioner education program in accordance with section nine hundred five of this chapter.  (c) A fixed percentage of the total funds accumulated in the statewide pool, including income from invested funds, shall be  deposited  by  the commissioner  into  the miscellaneous special revenue fund - 339, health care planning account, which is established for  services  and  expenses for  health  planning, for purposes of: (i) per capita support of health systems agencies, provided no health systems agency shall  receive  less than  two  hundred  fifty  thousand dollars annually from the per capita allocation, and provided further that a health systems agency  receiving the  minimum  level of funding provided pursuant to a per capita formula shall also be  entitled  to  receive  matching  support;  (ii)  matching support for other contributions received by health systems agencies from qualified  sources as determined by the commissioner; (iii) five hundred thousand dollars for global budgeting demonstrations  grants  authorized pursuant  to  section twenty-eight hundred fourteen of this article; and (iv) five hundred thousand dollars for health networks grants authorized pursuant to section twenty-eight hundred fourteen of this  article.  For the  rate  period  January  first,  nineteen hundred ninety-four through December thirty-first,  nineteen  hundred  ninety-four  such  percentage shall be eight and eight-tenths percent, and for the rate period January first,  nineteen  hundred  ninety-five  through  December  thirty-first,  nineteen  hundred  ninety-six  such  percentage  shall  be   eight   and two-tenths percent.  (c-1)  Notwithstanding any other provision of law to the contrary, any unspent  funds  available  for  programs  and   services   pursuant   to subparagraphs  (iii) and (iv) of paragraph (c) of this subdivision as of April first, nineteen  hundred  ninety-five  and  any  additional  funds available  for programs and services pursuant to subparagraphs (iii) and (iv) of paragraph (c) of this subdivision for the  period  April  first, nineteen  hundred  ninety-five  through  December thirty-first, nineteen hundred  ninety-five  shall  be  transferred  by  the  commissioner  and deposited  and credited to the medical assistance program general fund - local assistance account.  (c-2) Notwithstanding any other provision  of  law  to  the  contrary, funds  accumulated  for  programs and services pursuant to subparagraphs (i) and (ii) of paragraph (c) of this subdivision for  nineteen  hundred ninety-five  shall  be transferred by the commissioner and deposited and credited to the general fund - local assistance account.  (d) A fixed percentage of the total funds accumulated in the statewide pool, including income from invested funds, shall be  deposited  by  the commissioner  and  credited  to  the emergency medical services training account established for purposes of section ninety-seven-q of the  state finance  law  for  services  and  expenses  related to emergency medical services training and administration. For the rate period January first, nineteen hundred ninety-four  through  December  thirty-first,  nineteen hundred  ninety-four,  such percentage shall be seventeen and six-tenths percent, for the rate period January first, nineteen hundred ninety-five through  December  thirty-first,  nineteen  hundred  ninety-five,   such percentage  shall  be  twenty-one  and eight-tenths percent, and for the rate period January first, nineteen hundred ninety-six through  December thirty-first,  nineteen  hundred  ninety-six,  such  percentage shall be twenty-one and eight-tenths percent.  (f) Distributions from the  pools  created  in  accordance  with  this subdivision   and  subdivision  fourteen-b  of  this  section,  and  the components of rates of payment or  charges  related  to  the  allowances provided in accordance with subdivision fourteen-b of this section shall not   be  included  in  gross  revenue  received  for  purposes  of  the assessments pursuant to subdivision eighteen of this section, subject to the provisions of paragraph (e) of subdivision eighteen of this section, and shall not be included in gross receipts received for purposes of the assessments pursuant to section twenty-eight  hundred  seven-d  of  this article,  subject  to  the  provisions  of subdivision twelve of section twenty-eight hundred seven-d of this article.  (g)  Notwithstanding  any  inconsistent   provisions   of   law,   the commissioner  may  borrow  from  regional or statewide pool reserves for pools established pursuant to  sections  twenty-eight  hundred  eight-c, twenty-eight  hundred seven-a or this section of this article such funds as shall be necessary,  not  to  exceed  the  amounts  projected  to  be available  pursuant  to  paragraph (d) of subdivision fourteen-b of this section, annually for distributions in accordance with  paragraphs  (a), (b),  (c),  (d)  and  (h)  of this subdivision for a rate year and shall refund  such  moneys  when  pool  funds  become  available  pursuant  to paragraphs  (a), (b), (c), (d) and (h) of this subdivision for such rate year.  (h) Notwithstanding any inconsistent provision  of  this  subdivision, prior to allocation of funds in accordance with paragraphs (a), (b), (c) and  (d)  of  this  subdivision  from  the allowance for the period July first,  nineteen  hundred  ninety-five  through  December  thirty-first, nineteen  hundred  ninety-five  and  from  the  allowance for the period  January first,  nineteen  hundred  ninety-six  through  June  thirtieth, nineteen  hundred  ninety-six, thirty-nine million five hundred thousand dollars from  the  nineteen  hundred  ninety-five  pool  and  forty-four million   five  hundred  thousand  dollars  from  the  nineteen  hundred ninety-six pool respectively shall be reserved by the commissioner  from the  amount  accumulated  in the statewide pool, proportionally based on the total amount of funds projected to be accumulated in  the  pool  for the  year,  for  additional  distributions  in accordance with paragraph (b-1) of subdivision nineteen of this section  to  programs  to  provide health  care  coverage  for  uninsured or underinsured children, and the balance  of  funds  accumulated  in  the   statewide   pool   shall   be proportionally allocated in accordance with paragraphs (a), (b), (c) and (d) of this subdivision.   * NB Effective until December 31, 2023   * 19-a.  Health  care  services allowance statewide pool distribution. Funds accumulated  in  the  statewide  pool  created  by  the  allowance authorized  in accordance with subparagraphs (ii) and (iii) of paragraph (a) of subdivision fourteen-b of this  section,  including  income  from invested  funds, shall be distributed or retained in accordance with the following:  (a) Funds  shall  be  transferred  to  primary  health  care  services regional  pools  created  by  the  commissioner, and shall be available, including income from invested funds, for  distributions  in  accordance with  section  twenty-eight hundred seven-bb of this article. Such funds shall be transferred to each regional pool so  that  the  regional  pool receives,   for   the  rate  periods  January  first,  nineteen  hundred ninety-four through December thirty-first, nineteen hundred  ninety-four fifty-one  and  five-tenths  percent,  January  first,  nineteen hundred ninety-five through December thirty-first, nineteen hundred  ninety-five forty-nine  and  six-tenths percent, and January first, nineteen hundred ninety-six  through  June   thirtieth,   nineteen   hundred   ninety-six forty-nine  and  six tenths percent of the total funds to be accumulated in the statewide pool from the allowance submitted by or  on  behalf  of hospitals  in  that  region. Such regions shall be those established for purposes of section two thousand nine hundred four-b of this chapter.  (b) A fixed percentage of the total funds accumulated in the statewide pool, including income from  invested  funds,  shall  be  available  for primary care education and training. For the rate periods January first, nineteen  hundred  ninety-four  through  December thirty-first, nineteen hundred ninety-four, such percentage shall be twenty-two  and  one-tenth percent,  January  first,  nineteen hundred ninety-five through December thirty-first, nineteen hundred ninety-five,  such  percentage  shall  be twenty  and  four-tenths  percent,  and  January first, nineteen hundred ninety-six through June thirtieth,  nineteen  hundred  ninety-six,  such percentage  shall  be  twenty  and  four-tenths  percent. Funds shall be available for distributions as follows:  (i) up to four million  dollars  annually  plus  income  thereon  from invested  funds  shall  be set aside and reserved from accumulated funds and may be accumulated for the following year for  distribution  by  the commissioner   for  primary  care  undergraduate  medical  education  in accordance with section nine hundred two of this chapter;  (ii) up to four million dollars  annually  plus  income  thereon  from invested  funds  shall  be set aside and reserved from accumulated funds and may be accumulated for the following year for  distribution  by  the commissioner  for  the  primary care physician loan repayment program in accordance with section nine hundred three of this chapter;  (iii) up to two million dollars  annually  plus  income  thereon  from invested  funds  shall  be set aside and reserved from accumulated funds  and may be accumulated for the following year for  distribution  by  the commissioner  for  the  primary care practitioner scholarship program in accordance with section nine hundred four of this chapter;  (iv)  up  to  two  million  dollars  annually plus income thereon from invested funds shall be set aside and reserved  from  accumulated  funds and  may  be  accumulated for the following year for distribution by the commissioner for the primary  care  practitioner  education  program  in accordance with section nine hundred five of this chapter;  (v)  the  balance remaining annually plus income thereon from invested funds shall be set aside and reserved from accumulated funds and may  be accumulated  from year to year for distributions by the commissioner for health care development in accordance with section nine hundred  six  of this chapter; and  (vi)  provided,  however,  that  the  commissioner  in  the absence of qualified  recipients  within  a  category  may  reallocate  any   funds remaining  or unallocated within such a category for distribution by the commissioner for the primary care practitioner  scholarship  program  in accordance  with  section  nine  hundred  four  of  this chapter and the primary care practitioner education program in accordance  with  section nine hundred five of this chapter.  (c) A fixed percentage of the total funds accumulated in the statewide pool  including  income  from  invested funds, shall be deposited by the commissioner into the miscellaneous special revenue fund -  339,  health care  planning  account,  which is established for services and expenses for health planning, for purposes of: (i) per capita support  of  health systems  agencies,  provided no health systems agency shall receive less than two hundred fifty thousand dollars annually  from  the  per  capita allocation,  and provided further that a health systems agency receiving the minimum level of funding provided pursuant to a per  capita  formula shall  also  be  entitled  to  receive  matching  support; (ii) matching support for other contributions received by health systems agencies from qualified sources as determined by the commissioner; (iii) five  hundred thousand  dollars  for global budgeting demonstrations grants authorized pursuant to section twenty-eight hundred fourteen of this  article;  and (iv) five hundred thousand dollars for health networks grants authorized pursuant  to  section twenty-eight hundred fourteen of this article. For the rate period January  first,  nineteen  hundred  ninety-four  through December  thirty-first,  nineteen  hundred  ninety-four  such percentage shall be eight and eight-tenths percent, and for the rate period January first, nineteen hundred ninety-five  through  June  thirtieth,  nineteen hundred  ninety-six  such  percentage  shall  be  eight  and  two-tenths percent.  (c-1) Notwithstanding any other provision of law to the contrary,  any unspent   funds   available   for  programs  and  services  pursuant  to subparagraphs (iii) and (iv) of paragraph (c) of this subdivision as  of April  first,  nineteen  hundred  ninety-five  and  any additional funds available for programs and services pursuant to subparagraphs (iii)  and (iv)  of  paragraph  (c) of this subdivision for the period April first, nineteen hundred ninety-five  through  December  thirty-first,  nineteen hundred  ninety-five  shall  be  transferred  by  the  commissioner  and deposited and credited to the medical assistance  program  general  fund local assistance account.  (c-2)  Notwithstanding  any  other  provision  of law to the contrary, funds accumulated for programs and services  pursuant  to  subparagraphs (i)  and  (ii) of paragraph (c) of this subdivision for nineteen hundred ninety-five shall be transferred by the commissioner and  deposited  and credited to the general fund - local assistance account.  (d) A fixed percentage of the total funds accumulated in the statewide pool,  including  income  from invested funds, shall be deposited by the commissioner and credited to the  emergency  medical  services  training account  established for purposes of section ninety-seven-q of the state finance  law  for  services  and  expenses  related to emergency medical services training and administration. For the rate period January first, nineteen hundred ninety-four  through  December  thirty-first,  nineteen hundred  ninety-four,  such percentage shall be seventeen and six-tenths percent, for the rate period January first, nineteen hundred ninety-five through  December  thirty-first,  nineteen  hundred  ninety-five,   such percentage  shall  be  twenty-one  and eight-tenths percent, and for the rate period January first,  nineteen  hundred  ninety-six  through  June thirtieth,   nineteen  hundred  ninety-six,  such  percentage  shall  be twenty-one and eight-tenths percent.  (e) If on September  thirtieth,  nineteen  hundred  ninety-seven,  any funds  accumulated  over  the  period  January  first,  nineteen hundred ninety-four through June thirtieth, nineteen hundred ninety-six  in  the regional pools established pursuant to paragraph (a) of this subdivision are  unused or uncommitted for the allocations provided for, such unused or uncommitted funds shall be reallocated for use in accordance with the provisions of subdivision seventeen of this section.  (f) Distributions from the  pools  created  in  accordance  with  this subdivision   and  subdivision  fourteen-b  of  this  section,  and  the components of rates of payment or  charges  related  to  the  allowances provided in accordance with subdivision fourteen-b of this section shall not   be  included  in  gross  revenue  received  for  purposes  of  the assessments pursuant to subdivision eighteen of this section, subject to the provisions of paragraph (e) of subdivision eighteen of this section, and shall not be included in gross receipts received for purposes of the assessments pursuant to section twenty-eight  hundred  seven-d  of  this article,  subject  to  the  provisions  of subdivision twelve of section twenty-eight hundred seven-d of this article.  (g)  Notwithstanding  any  inconsistent   provisions   of   law,   the commissioner  may  borrow  from  regional or statewide pool reserves for pools established pursuant to  sections  twenty-eight  hundred  eight-c, twenty-eight  hundred seven-a or this section of this article such funds as shall be necessary,  not  to  exceed  the  amounts  projected  to  be available  pursuant  to  paragraph (d) of subdivision fourteen-b of this section, annually for distributions in accordance with  paragraphs  (a), (b),  (c),  (d)  and  (h)  of this subdivision for a rate year and shall refund  such  moneys  when  pool  funds  become  available  pursuant  to paragraphs  (a), (b), (c), (d) and (h) of this subdivision for such rate year.  (h) Notwithstanding any inconsistent provision  of  this  subdivision, prior to allocation of funds in accordance with paragraphs (a), (b), (c) and  (d)  of  this  subdivision  from  the allowance for the period July first,  nineteen  hundred  ninety-five  through  December  thirty-first, nineteen  hundred  ninety-five  and  from  the  allowance for the period January first,  nineteen  hundred  ninety-six  through  June  thirtieth, nineteen  hundred  ninety-six, thirty-nine million five hundred thousand dollars from  the  nineteen  hundred  ninety-five  pool  and  twenty-two million  two  hundred  fifty  thousand dollars from the nineteen hundred ninety-six pool respectively shall be reserved by the commissioner  from the  amount  accumulated  in the statewide pool, proportionally based on the total amount of funds projected to be accumulated in  the  pool  for the  year,  for  additional  distributions  in accordance with paragraph (b-1) of subdivision nineteen of this section  to  programs  to  provide health  care  coverage  for  uninsured or underinsured children, and the  balance  of  funds  accumulated  in  the   statewide   pool   shall   be proportionally  allocated in accordance with paragraphs (a), (b),(c) and (d) of this subdivision.   * NB Effective December 31, 2023   * 19-b.  Funds  accumulated  in  the  statewide  pool  created  by the assessment authorized in accordance with subdivision  eighteen  of  this section  for  a period during the period January first, nineteen hundred ninety-seven through December thirty-first, nineteen hundred ninety-nine and periods on and after January first, two thousand,  including  income from  invested  funds,  shall  be  transferred  by  the commissioner and consolidated with funds  accumulated  from  the  allowance  pursuant  to subdivision  two of section twenty-eight hundred seven-j of this article for such period and allocated in accordance  with  subdivision  nine  of section twenty-eight hundred seven-j of this article.   * NB Effective until December 31, 2023   * 19-b.  Funds  accumulated  in  the  statewide  pool  created  by the assessment authorized in accordance with subdivision  eighteen  of  this section  for  a period during the period January first, nineteen hundred ninety-seven   through   December   thirty-first,    nineteen    hundred ninety-nine,  including income from invested funds, shall be transferred by the commissioner and consolidated with  funds  accumulated  from  the allowance  pursuant  to  subdivision two of section twenty-eight hundred seven-j of this article for such period and allocated in accordance with subdivision  nine  of  section  twenty-eight  hundred  seven-j  of  this article.   * NB Effective and repealed December 31, 2023   20.  Payments  to  pools.  (a)  Payments  by  or  on behalf of general hospitals to bad debt and charity care regional pools of funds due based on the allowance included  in  rates  and  charges  in  accordance  with paragraph  (c)  of  subdivision fourteen of this section and to regional pools created pursuant to paragraph (b) of subdivision fourteen-b and to a statewide pool  created  pursuant  to  paragraph  (b)  of  subdivision fourteen-c  of this section shall be made on a time schedule established by the  council,  subject  to  the  approval  of  the  commissioner,  by regulation;  provided,  however,  that estimated payments of amounts due for patients discharged in a  calendar  month  commencing  on  or  after October  first,  nineteen  hundred  ninety-one must be made within sixty days of the end of each month unless payments of actual amounts due  for such  calendar  months have been made within such sixty day time period. Upon receipt of notification from the commissioner, the comptroller,  or a  fiscal  intermediary designated by the director of the budget, or the commissioner  of  social  services,  or  a  corporation  organized   and operating in accordance with article forty-three of the insurance law or an  organization operating in accordance with article forty-four of this chapter shall withhold from the amount of any payment to be made by  the state  or  such  article  forty-three  corporation or article forty-four organization to a general hospital the amount of any arrearage resulting from such general hospital's failure to make a  timely  payment  to  the pools of funds due based on the allowances included in rates and charges in  accordance with paragraph (c) of subdivision fourteen, paragraph (a) of subdivision fourteen-b and paragraph (a) of subdivision fourteen-c of this section. Upon  withholding  such  amount,  the  comptroller,  or  a designated  fiscal intermediary, or the commissioner of social services, or a corporation organized and  operating  in  accordance  with  article forty-three  of  the  insurance  law  or  an  organization  operating in accordance with  article  forty-four  of  this  chapter  shall  pay  the commissioner, or his designee, such amount withheld for deposit into the applicable  pool. Any general hospital in arrears resulting from failure  to make a timely  payment  to  a  pool  shall  not  be  eligible  for  a distribution  from  a  bad  debt  and  charity  care  regional  pool  in accordance  with  subdivision  seventeen  of  this  section  until  such arrearage is satisfied.  (b)  (i) Payments by or on behalf of general hospitals to the bad debt and charity care and capital  statewide  pool  of  funds  due  from  the assessments  pursuant  to  subdivision eighteen of this section shall be made on a time schedule established  by  the  council,  subject  to  the approval  of  the  commissioner,  by regulation; provided, however, that estimated payments of amounts due for patients discharged in a  calendar month  commencing on or after October first, nineteen hundred ninety-one must be made within sixty days of the end of each month unless  payments of  actual  amounts  due  for such calendar months have been made within such sixty day time  period.  Upon  receipt  of  notification  from  the commissioner,  the  comptroller,  or a fiscal intermediary designated by the director of the budget, or a corporation organized and operating  in accordance   with  article  forty-three  of  the  insurance  law  or  an organization operating in accordance with  article  forty-four  of  this chapter  shall withhold from the amount of any payment to be made by the state or such article  forty-three  corporation  or  article  forty-four organization to a general hospital the amount of any arrearage resulting from such general hospital's failure to make a timely payment to the bad debt  and  charity care and capital statewide pool of funds due from the assessments.  Upon  withholding  such  amount,  the  comptroller,  or  a designated fiscal intermediary, or a corporation organized and operating in  accordance  with  article  forty-three  of  the  insurance law or an organization operating in accordance with  article  forty-four  of  this chapter  shall  pay  the  commissioner,  or  his  designee,  such amount withheld for deposit into the applicable pool. Any general  hospital  in arrears  resulting from failure to make a timely payment to the bad debt and charity care and capital statewide pool shall not be eligible for  a distribution  from  the  bad  debt  and  charity  care regional pools in accordance with subdivision seventeen of this section or  the  bad  debt and   charity  care  and  capital  statewide  pool  in  accordance  with subdivision nineteen of this section until such arrearage is satisfied.  (ii) For periods on  and  after  January  first,  two  thousand  five, reports  submitted  by general hospitals to implement the assessment set forth in  subdivision  eighteen  of  this  section  shall  be  submitted electronically  in  a  form  as  may  be  required  by the commissioner; provided, however, general hospitals are not prohibited from  submitting reports  electronically  on  a  voluntary  basis prior to such date, and provided  further,  however,  that  all  such   electronic   submissions submitted on and after July first, two thousand twelve shall be verified with an electronic signature as prescribed by the commissioner.  (c)  (i)  Interest  shall  be due and payable to the commissioner by a general hospital or by  a  payor  paying  directly  to  a  pool  on  the difference  between the amount paid to a pool and the amount due to such pool by the hospital or payor from the day of the month the payment  was due  until  the  date  of  payment. The rate of interest shall be twelve percent per annum or at the rate of interest set by the commissioner  of taxation  and  finance  with respect to underpayments of tax pursuant to subsection (e) of section one thousand ninety-six of the tax  law  minus four  percentage points. Interest under this paragraph shall not be paid if the amount thereof is less than one dollar. Interest may be collected by the commissioner in the same manner as an arrearage pursuant to  this subdivision.  (ii)  If a payment by a general hospital or by a payor paying directly to a pool is less than seventy percent of the amount due to such pool by  the hospital or payor, a  penalty  shall  be  due  and  payable  to  the commissioner  by the hospital or payor of five percent of the difference between the amount paid to the pool and the amount due to such pool when the  failure  to  pay is for a duration of not more than one month after the due date of the payment with an additional  five  percent  for  each additional   month   or  fraction  thereof  during  which  such  failure continues, not exceeding twenty-five percent in the aggregate. A penalty may be collected by the commissioner in the same manner as an  arrearage pursuant to this subdivision.   21.  Maximum  distributions.  (a)  No  general hospital may receive in total from the distributions made in accordance with  paragraph  (b)  of subdivision  fourteen-c, paragraphs (a) and (b) of subdivision seventeen and paragraphs (c), (d) and (e) of subdivision nineteen of this  section an  amount  which  exceeds  its need for financing losses related to bad debts and the costs of charity care  as  defined  in  paragraph  (b)  of subdivision fourteen of this section.   * (b)(i)  No  public  general  hospital  may  receive  in  total  from disproportionate share payment distributions  made  in  accordance  with subdivision seventeen of this section and adjustments in accordance with subdivisions  fourteen-a  and  fourteen-d of this section for the period April first, nineteen hundred ninety-four through December thirty-first, nineteen hundred ninety-four or for annual  rate  periods  beginning  on January  first  on  or after January first, nineteen hundred ninety-five through December thirty-first, nineteen hundred ninety-six, or  made  in accordance with section twenty-eight hundred seven-k of this article and adjustments  in  accordance  with subdivision fourteen-f of this section for annual periods beginning on  January  first  on  and  after  January first,  nineteen  hundred  ninety-seven  through  December thirty-first, nineteen hundred  ninety-nine  and  on  and  after  January  first,  two thousand  an  amount which exceeds the costs incurred during such period of furnishing inpatient and ambulatory hospital services, net of medical assistance payments pursuant to title eleven  of  article  five  of  the social services law, other than disproportionate share payments pursuant to  subdivision  twenty-six  of  this section or subdivision thirteen of section twenty-eight hundred seven-k of this article,  and  payments  by uninsured  patients,  by  the  hospital  to  individuals  who either are eligible for medical assistance pursuant to title eleven of article five of the social services law or have no health insurance or  other  source of  third party coverage; provided, however, that the commissioner shall make such increase to such  maximum  or  to  the  manner  in  which  the limitation  on  disproportionate  share  payments  is  applied  as shall increase the maximum  limit  for  a  period  or  part  of  a  period  as authorized  by  federal  law  or  regulation  or  the  secretary  of the department  of  health  and  human  services  for  purposes  of  federal financial  participation  pursuant  to  title  XIX of the federal social security act. For purposes of this  paragraph,  payments  to  a  general hospital for services provided to indigent patients made by the state or a  unit  of local government within the state shall not be considered to be a source of third party payment.  (ii) Reductions pursuant to  this  paragraph  shall  be  made  in  the following sequence:  (A)  for  periods  through  December  thirty-first,  nineteen  hundred ninety-six, adjustments in accordance  with  subdivision  fourteen-d  of this  section;  adjustments in accordance with subdivision fourteen-a of this section; and distributions in accordance with subdivision seventeen of this section, and  (B) for periods during the  period  January  first,  nineteen  hundred ninety-seven through December thirty-first, nineteen hundred ninety-nine  and  on and after January first, two thousand, adjustments in accordance with subdivision  fourteen-f  of  this  section;  and  distributions  in accordance with section twenty-eight hundred seven-k of this article.  (iii)  (A)  In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective for distributions in accordance with subdivision seventeen of this  section  for  a  general  hospital,  such general  hospital  shall  receive  a supplementary distribution not as a disproportionate share payment and  not  subject  to  federal  financial participation  from funds available pursuant to subdivision seventeen of this section for periods through December thirty-first, nineteen hundred ninety-six equal to one-half of such reduction.  (B) In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective for distributions in accordance with section twenty-eight hundred seven-k of this article  for  a  general  hospital, such  general hospital shall receive a supplementary distribution not as a disproportionate share payment and not subject  to  federal  financial participation  from  funds  available  pursuant  to section twenty-eight hundred seven-k of this article for periods during  the  period  January first,  nineteen  hundred  ninety-seven  through  December thirty-first, nineteen hundred  ninety-nine  and  on  and  after  January  first,  two thousand equal to one-half of such reduction.   * NB Effective until December 31, 2023   * (b)(i)  No  public  general  hospital  may  receive  in  total  from disproportionate share payment distributions  made  in  accordance  with subdivision seventeen of this section and adjustments in accordance with subdivisions  fourteen-a  and  fourteen-d of this section for the period April first, nineteen hundred ninety-four through December thirty-first, nineteen hundred ninety-four or for annual  rate  periods  beginning  on January  first  on  or after January first, nineteen hundred ninety-five through December thirty-first, nineteen hundred ninety-six, or  made  in accordance with section twenty-eight hundred seven-k of this article and adjustments  in  accordance  with subdivision fourteen-f of this section for annual periods beginning on  January  first  on  and  after  January first,  nineteen  hundred  ninety-seven  through  December thirty-first, nineteen hundred ninety-nine an amount which exceeds the costs  incurred during  such  period  of  furnishing  inpatient  and ambulatory hospital services, net of medical assistance payments pursuant to title eleven of article five of the social services  law,  other  than  disproportionate share  payments  pursuant  to  subdivision twenty-six of this section or subdivision thirteen of section twenty-eight  hundred  seven-k  of  this article,  and  payments  by  uninsured  patients,  by  the  hospital  to individuals who either are eligible for medical assistance  pursuant  to title  eleven  of  article  five  of  the social services law or have no health insurance or other source  of  third  party  coverage;  provided, however,  that the commissioner shall make such increase to such maximum or to the manner in  which  the  limitation  on  disproportionate  share payments  is applied as shall increase the maximum limit for a period or part of a period as authorized by  federal  law  or  regulation  or  the secretary of the department of health and human services for purposes of federal  financial  participation  pursuant  to title XIX of the federal social security act. For purposes  of  this  paragraph,  payments  to  a general  hospital for services provided to indigent patients made by the state or a unit of local  government  within  the  state  shall  not  be considered to be a source of third party payment.  (ii)  Reductions  pursuant  to  this  paragraph  shall  be made in the following sequence:  (A)  for  periods  through  December  thirty-first,  nineteen  hundred ninety-six,  adjustments  in  accordance  with subdivision fourteen-d of  this section; adjustments in accordance with subdivision  fourteen-a  of this section; and distributions in accordance with subdivision seventeen of this section, and  (B)  for  periods  during  the  period January first, nineteen hundred ninety-seven   through   December   thirty-first,    nineteen    hundred ninety-nine,  adjustments  in  accordance with subdivision fourteen-f of this section; and distributions in accordance with section  twenty-eight hundred seven-k of this article.  (iii)  (A)  In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective for distributions in accordance with subdivision seventeen of this  section  for  a  general  hospital,  such general  hospital  shall  receive  a supplementary distribution not as a disproportionate share payment and  not  subject  to  federal  financial participation  from funds available pursuant to subdivision seventeen of this section for periods through December thirty-first, nineteen hundred ninety-six.  (B) In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective for distributions in accordance with section twenty-eight hundred seven-k of this article  for  a  general  hospital, such  general hospital shall receive a supplementary distribution not as a disproportionate share payment and not subject  to  federal  financial participation  from  funds  available  pursuant  to section twenty-eight hundred seven-k of this article for periods during  the  period  January first,  nineteen  hundred  ninety-seven  through  December thirty-first, nineteen hundred ninety-nine equal to one-half of such reduction.   * NB Effective and expires December 31, 2023   * (b) (i) No  public  general  hospital  may  receive  in  total  from disproportionate  share  payment  distributions  made in accordance with subdivision seventeen of this section and adjustments in accordance with subdivisions fourteen-a and fourteen-d of this section  for  the  period April first, nineteen hundred ninety-four through December thirty-first, nineteen  hundred  ninety-four  or  for  annual rate period beginning on January first on or after January first, nineteen hundred ninety-five an amount which exceeds the costs incurred during such period of furnishing inpatient and ambulatory hospital services, net  of  medical  assistance payments pursuant to title eleven of article five of the social services law,  other than disproportionate share payments pursuant to subdivision twenty-six of this section, and payments by uninsured patients,  by  the hospital  to  individuals who either are eligible for medical assistance pursuant to title eleven of article five of the social services  law  or have  no  health  insurance  or  other  source  of third party coverage; provided, however, that the commissioner shall  make  such  increase  to such   maximum   or   to   the   manner   in  which  the  limitation  on disproportionate share payments is applied as shall increase the maximum limit for a period or part of a period as authorized by federal  law  or regulation  or  the  secretary  of  the  department  of health and human services for purposes of federal  financial  participation  pursuant  to title  XIX  of  the  federal  social  security act. For purposes of this paragraph, payments to a  general  hospital  for  services  provided  to indigent patients made by the state or a unit of local government within the state shall not be considered to be a source of third party payment.  (ii)  Reductions  pursuant  to  this  paragraph  shall  be made in the following  sequence:  adjustments   in   accordance   with   subdivision fourteen-d  of  this section; adjustments in accordance with subdivision fourteen-a  of  this  section;  and  distributions  in  accordance  with subdivision seventeen of this section.  (iii)  In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective  for  distributions  in  accordance  with  subdivision  seventeen  of  this  section  for  a general hospital, such general hospital shall receive a supplementary  distribution  not  as  a disproportionate  share  payment  and  not  subject to federal financial participation  from funds available pursuant to subdivision seventeen of this section equal to one-half of such reduction.   * NB Effective December 31, 2023   * (c)(i) No general hospital other than a public general hospital  may receive  in total from disproportionate share payment distributions made in accordance with paragraph (b) of subdivision fourteen-c,  subdivision seventeen  and  paragraphs  (c)  and (d) of subdivision nineteen of this section and adjustments in accordance  with  subdivision  fourteen-d  of this  section  for  the period April first, nineteen hundred ninety-five through December thirty-first, nineteen hundred ninety-five or  for  the annual   rate  period  beginning  on  January  first,  nineteen  hundred ninety-six through December thirty-first, nineteen  hundred  ninety-six, or  made in accordance with section twenty-eight hundred seven-k of this article for annual periods beginning  on  January  first  on  and  after January   first,   nineteen   hundred   ninety-seven   through  December thirty-first, nineteen hundred ninety-nine  and  on  and  after  January first,  two  thousand  an amount which exceeds the costs incurred during such period of furnishing inpatient and  ambulatory  hospital  services, net  of  medical assistance payments pursuant to title eleven of article five of the social  services  law,  other  than  disproportionate  share payments   pursuant   to  subdivision  twenty-six  of  this  section  or subdivision thirteen of section twenty-eight  hundred  seven-k  of  this article,  and  payments  by  uninsured  patients,  by  the  hospital  to individuals who either are eligible for medical assistance  pursuant  to title  eleven  of  article  five  of  the social services law or have no health insurance or other source  of  third  party  coverage;  provided, however,  that  the  commissioner  shall  make such modifications to the manner in which the limitation on  disproportionate  share  payments  is applied  to  such  hospitals  as  shall increase the maximum limit for a period or part of a period as authorized by federal law or regulation or the secretary of  the  department  of  health  and  human  services  for purposes of federal financial participation pursuant to title XIX of the federal social security act. For purposes of this paragraph, payments to a  general  hospital  for services provided to indigent patients made by the state or a unit of local government within the state  shall  not  be considered to be a source of third party payment.  (ii)(A)  Reductions  pursuant  to  this  paragraph for periods through December thirty-first, nineteen hundred ninety-six shall be made in  the following   sequence   for  general  hospitals  other  than  financially distressed  hospitals:  adjustments  in  accordance   with   subdivision fourteen-d  of  this  section;  and  distributions  in  accordance  with subdivision seventeen of this section.  (B) Reductions pursuant to this paragraph for periods through December thirty-first, nineteen hundred ninety-six shall be made in the following sequence for general  hospitals  designated  as  financially  distressed hospitals: distributions in accordance with paragraph (b) of subdivision fourteen-c  of this section; distributions in accordance with paragraphs (c) and (d) of subdivision nineteen of this section;  and  distributions in accordance with subdivision seventeen of this section.  (C)  Reductions  pursuant  to  this  paragraph  for periods during the period January first, nineteen  hundred  ninety-seven  through  December thirty-first,  nineteen  hundred  ninety-nine  and  on and after January first, two thousand, shall be made from distributions in accordance with section twenty-eight hundred seven-k of this article.  (iii) (A) In the event a reduction pursuant to subparagraphs  (i)  and (ii) of this paragraph is effective for distributions in accordance with paragraph  (b)  of subdivision fourteen-c of this section, paragraph (c) or (d) of subdivision nineteen of this section,  subdivision  fourteen-d of  this  section or subdivision seventeen of this section for a general hospital,  such  general  hospital   shall   receive   a   supplementary distribution  not as a disproportionate share payment and not subject to federal financial participation from funds available  pursuant  to  such subdivisions  equal  to  one-half  of such reduction for periods through December thirty-first, nineteen hundred ninety-six.  (B) In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective for distributions in accordance with section twenty-eight hundred seven-k of this article  for  a  general  hospital, such  general hospital shall receive a supplementary distribution not as a disproportionate share payment and not subject  to  federal  financial participation  from  funds  available  pursuant  to section twenty-eight hundred seven-k of this article for periods during  the  period  January first,  nineteen  hundred  ninety-seven  through  December thirty-first, nineteen hundred  ninety-nine  and  on  and  after  January  first,  two thousand equal to one-half of such reduction.   * NB Effective until December 31, 2023   * (c)(i)  No general hospital other than a public general hospital may receive in total from disproportionate share payment distributions  made in  accordance with paragraph (b) of subdivision fourteen-c, subdivision seventeen and paragraphs (c) and (d) of  subdivision  nineteen  of  this section  and  adjustments  in  accordance with subdivision fourteen-d of this section for the period April first,  nineteen  hundred  ninety-five through  December  thirty-first, nineteen hundred ninety-five or for the annual  rate  period  beginning  on  January  first,  nineteen   hundred ninety-six  through  December thirty-first, nineteen hundred ninety-six, or made in accordance with section twenty-eight hundred seven-k of  this article  for  annual  periods  beginning  on  January first on and after January  first,   nineteen   hundred   ninety-seven   through   December thirty-first,  nineteen  hundred ninety-nine an amount which exceeds the costs incurred during such period of furnishing inpatient and ambulatory hospital services, net of medical assistance payments pursuant to  title eleven   of  article  five  of  the  social  services  law,  other  than disproportionate share payments pursuant to  subdivision  twenty-six  of this  section  or  subdivision  thirteen of section twenty-eight hundred seven-k of this article, and payments  by  uninsured  patients,  by  the hospital  to  individuals who either are eligible for medical assistance pursuant to title eleven of article five of the social services  law  or have  no  health  insurance  or  other  source  of third party coverage; provided, however, that the commissioner shall make  such  modifications to the manner in which the limitation on disproportionate share payments is  applied  to such hospitals as shall increase the maximum limit for a period or part of a period as authorized by federal law or regulation or the secretary of  the  department  of  health  and  human  services  for purposes of federal financial participation pursuant to title XIX of the federal social security act. For purposes of this paragraph, payments to a  general  hospital  for services provided to indigent patients made by the state or a unit of local government within the state  shall  not  be considered to be a source of third party payment.  (ii)(A)  Reductions  pursuant  to  this  paragraph for periods through December thirty-first, nineteen hundred ninety-six shall be made in  the following   sequence   for  general  hospitals  other  than  financially distressed  hospitals:  adjustments  in  accordance   with   subdivision  fourteen-d  of  this  section;  and  distributions  in  accordance  with subdivision seventeen of this section.  (B) Reductions pursuant to this paragraph for periods through December thirty-first, nineteen hundred ninety-six shall be made in the following sequence  for  general  hospitals  designated  as financially distressed hospitals: distributions in accordance with paragraph (b) of subdivision fourteen-c of this section; distributions in accordance with  paragraphs (c)  and  (d) of subdivision nineteen of this section; and distributions in accordance with subdivision seventeen of this section.  (C) Reductions pursuant to  this  paragraph  for  periods  during  the period  January  first,  nineteen  hundred ninety-seven through December thirty-first,  nineteen  hundred  ninety-nine,  shall   be   made   from distributions in accordance with section twenty-eight hundred seven-k of this article.  (iii)  (A)  In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective for distributions in accordance with paragraph (b) of subdivision fourteen-c of this section,  paragraph  (c) or  (d)  of subdivision nineteen of this section, subdivision fourteen-d of this section or subdivision seventeen of this section for  a  general hospital,   such   general   hospital   shall  receive  a  supplementary distribution not as a disproportionate share payment and not subject  to federal  financial  participation  from funds available pursuant to such subdivisions equal to one-half of such  reduction  for  periods  through December thirty-first, nineteen hundred ninety-six.  (B) In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective for distributions in accordance with section twenty-eight  hundred  seven-k  of  this article for a general hospital, such general hospital shall receive a supplementary distribution not  as a  disproportionate  share  payment and not subject to federal financial participation from funds  available  pursuant  to  section  twenty-eight hundred  seven-k  of  this article for periods during the period January first, nineteen  hundred  ninety-seven  through  December  thirty-first, nineteen hundred ninety-nine equal to one-half of such reduction.   * NB Effective and expires December 31, 2023   * (c) (i) No general hospital other than a public general hospital may receive  in total from disproportionate share payment distributions made in accordance with paragraph (b) of subdivision fourteen-c,  subdivision seventeen  and  paragraphs  (c)  and (d) of subdivision nineteen of this section and adjustments in accordance  with  subdivision  fourteen-d  of this  section  for  the period April first, nineteen hundred ninety-five through December thirty-first, nineteen hundred ninety-five or  for  the annual   rate  period  beginning  on  January  first,  nineteen  hundred ninety-six an amount which exceeds the costs incurred during such period of furnishing inpatient and ambulatory hospital services, net of medical assistance payments pursuant to title eleven  of  article  five  of  the social services law, other than disproportionate share payments pursuant to  subdivision  twenty-six  of  this section, and payments by uninsured patients, by the hospital to individuals who  either  are  eligible  for medical  assistance  pursuant  to  title  eleven  of article five of the social services law or have no health insurance or other source of third party coverage; provided, however, that the commissioner shall make such modifications to the manner in which the limitation on  disproportionate share  payments  is  applied  to  such  hospitals  as shall increase the maximum limit for a period or part of a period as authorized by  federal law or regulation or the secretary of the department of health and human services  for  purposes  of  federal financial participation pursuant to title XIX of the federal social  security  act.  For  purposes  of  this paragraph,  payments  to  a  general  hospital  for services provided to  indigent patients made by the state or a unit of local government within the state shall not be considered to be a source of third party payment.  (ii)(A)  Reductions  pursuant  to  this paragraph shall be made in the following  sequence  for  general  hospitals  other   than   financially distressed   hospitals:   adjustments  in  accordance  with  subdivision fourteen-d  of  this  section;  and  distributions  in  accordance  with subdivision seventeen of this section.  (B)  Reductions  pursuant  to  this  paragraph  shall  be  made in the following sequence  for  general  hospitals  designated  as  financially distressed  hospitals: distributions in accordance with paragraph (b) of subdivision fourteen-c of this section; distributions in accordance with paragraphs (c) and (d) of subdivision  nineteen  of  this  section;  and distributions in accordance with subdivision seventeen of this section.  (iii)  In the event a reduction pursuant to subparagraphs (i) and (ii) of this paragraph is effective  for  distributions  in  accordance  with paragraph  (b)  of subdivision fourteen-c of this section, paragraph (c) or (d) of subdivision nineteen of this section,  subdivision  fourteen-d of  this  section or subdivision seventeen of this section for a general hospital,  such  general  hospital   shall   receive   a   supplementary distribution  not as a disproportionate share payment and not subject to federal financial participation from funds available  pursuant  to  such subdivisions equal to one-half of such reduction.   * NB Effective December 31, 2023   * (d)(i)  Commencing  April  first,  nineteen  hundred ninety-four, no general hospital may  be  eligible  to  receive  disproportionate  share payments  determined  in  accordance with subdivision twenty-six of this section through December thirty-first, nineteen hundred ninety-six or in accordance with section twenty-eight hundred seven-k of this article for periods during the period January first, nineteen  hundred  ninety-seven through  December  thirty-first, nineteen hundred ninety-nine and on and after January first, two thousand unless the hospital has  an  inpatient utilization  rate  for  patients eligible for payments pursuant to title eleven of article five of the social services law eligible  for  federal financial participation pursuant to title nineteen of the federal social security act of not less than one percent.  (ii)  In  the  event  a  general  hospital is disqualified pursuant to subparagraph (i) of this paragraph from receiving disproportionate share payments for a period, such general hospital shall receive distributions not as disproportionate  share  payments  and  not  subject  to  federal financial  participation  from  funds  available pursuant to subdivision seventeen of this section for  periods  through  December  thirty-first, nineteen  hundred  ninety-six,  and  pursuant  to  section  twenty-eight hundred seven-k of this article for periods during  the  period  January first,  nineteen  hundred  ninety-seven  through  December thirty-first, nineteen hundred  ninety-nine  and  on  and  after  January  first,  two thousand  equal  to one-half of the distributions for which such general hospital would have been qualified pursuant to subdivision seventeen  of this section for periods through December thirty-first, nineteen hundred ninety-six, and pursuant to section twenty-eight hundred seven-k of this article  for  periods  during the period January first, nineteen hundred ninety-seven through December thirty-first, nineteen hundred ninety-nine and on and after January first, two thousand  without  consideration  of subparagraph (i) of this paragraph.   * NB Effective until December 31, 2023   * (d)(i)  Commencing  April  first,  nineteen  hundred ninety-four, no general hospital may  be  eligible  to  receive  disproportionate  share payments  determined  in  accordance with subdivision twenty-six of this section through December thirty-first, nineteen hundred ninety-six or in  accordance with section twenty-eight hundred seven-k of this article for periods during the period January first, nineteen  hundred  ninety-seven through  December  thirty-first, nineteen hundred ninety-nine unless the hospital  has  an  inpatient  utilization rate for patients eligible for payments pursuant to title eleven of article five of the social services law eligible for  federal  financial  participation  pursuant  to  title nineteen  of  the  federal  social  security  act  of  not less than one percent.  (ii) In the event a  general  hospital  is  disqualified  pursuant  to subparagraph (i) of this paragraph from receiving disproportionate share payments for a period, such general hospital shall receive distributions not  as  disproportionate  share  payments  and  not  subject to federal financial participation from funds  available  pursuant  to  subdivision seventeen  of  this  section  for periods through December thirty-first, nineteen  hundred  ninety-six,  and  pursuant  to  section  twenty-eight hundred  seven-k  of  this article for periods during the period January first, nineteen  hundred  ninety-seven  through  December  thirty-first, nineteen  hundred ninety-nine equal to one-half of the distributions for which such general  hospital  would  have  been  qualified  pursuant  to subdivision  seventeen  of  this  section  for  periods through December thirty-first, nineteen  hundred  ninety-six,  and  pursuant  to  section twenty-eight  hundred  seven-k  of  this  article for periods during the period January first, nineteen  hundred  ninety-seven  through  December thirty-first,  nineteen  hundred  ninety-nine  without  consideration of subparagraph (i) of this paragraph.   * NB Effective and expires December 31, 2023   * (d)(i) Commencing April  first,  nineteen  hundred  ninety-four,  no general  hospital  may  be  eligible  to  receive disproportionate share payments determined in accordance with subdivision  twenty-six  of  this section  unless  the  hospital  has  an  inpatient  utilization rate for patients eligible for payments pursuant to title eleven of article  five of  the social services law eligible for federal financial participation pursuant to title nineteen of the federal social  security  act  of  not less than one percent.  (ii)  In  the  event  a  general  hospital is disqualified pursuant to subparagraph (i) of this paragraph from receiving disproportionate share payments for a period, such general hospital shall receive distributions not as disproportionate  share  payments  and  not  subject  to  federal financial  participation  from  funds  available pursuant to subdivision seventeen of this section equal to one-half  of  the  distributions  for which  such  general  hospital  would  have  been  qualified pursuant to subdivision  seventeen  of  this  section   without   consideration   of subparagraph (i) of this paragraph.   * NB Effective December 31, 2023   * (e)  For purposes of calculations pursuant to paragraphs (b) and (c) of  this  subdivision  of   maximum   disproportionate   share   payment distributions  for  a year or part thereof, costs incurred of furnishing hospital  services  net  of  medical  assistance  payments,  other  than disproportionate  share  payments,  and  payments  by uninsured patients shall be determined initially based on base year data and statistics for the base year two years immediately preceding the year projected to  the year  by  the trend factor determined in accordance with subdivision ten of this section and shall be  subsequently  revised  to  reflect  actual period  data  and  statistics.  For purposes of calculations pursuant to paragraph  (d)  of  this   subdivision   of   eligibility   to   receive disproportionate share payments for a year or part thereof, the hospital inpatient  utilization  rate  shall  be  determined  based  on base year statistics  in  accordance  with  a  methodology  established   by   the  commissioner,  and  costs incurred of furnishing hospital services shall be determined in  accordance  with  a  methodology  established  by  the commissioner  consistent  with  requirements  of  the  secretary  of the department  of  health  and  human  services  for  purposes  of  federal financial participation pursuant to title  XIX  of  the  federal  social security act in disproportionate share payments.   * NB Effective until December 31, 2023   * (e)  For purposes of calculations pursuant to paragraphs (b) and (c) of  this  subdivision  of   maximum   disproportionate   share   payment distributions  for  a  rate  year  or  part  thereof,  costs incurred of furnishing hospital services net of medical assistance  payments,  other than disproportionate share payments, and payments by uninsured patients shall be determined initially based on base year data and statistics for the base year two years immediately preceding the rate year projected to the  rate  year  by  the  trend  factor  determined  in  accordance with subdivision ten of this section and shall  be  subsequently  revised  to reflect  actual  rate  period  data  and  statistics.  For  purposes  of calculations  pursuant  to  paragraph  (d)  of   this   subdivision   of eligibility  to  receive disproportionate share payments for a rate year or part thereof,  the  hospital  inpatient  utilization  rate  shall  be determined   based   on  base  year  statistics  in  accordance  with  a methodology established by  the  commissioner,  and  costs  incurred  of furnishing  hospital  services  shall be determined in accordance with a methodology established by the commissioner consistent with requirements of the secretary of the department of  health  and  human  services  for purposes of federal financial participation pursuant to title XIX of the federal social security act in disproportionate share payments.   * NB Effective December 31, 2023  (e-1) For periods on and after January first, two thousand eleven, for purposes  of  calculations  pursuant  to  paragraphs (b) and (c) of this subdivision of maximum disproportionate share payment distributions  for a  rate  year  or  part  thereof,  costs incurred of furnishing hospital services net of medical assistance payments, other than disproportionate share payments, and payments by uninsured patients  shall  for  the  two thousand  eleven  calendar  year, shall be determined initially based on each hospital's submission of  a  fully  completed  two  thousand  eight disproportionate  share hospital data collection tool, which is required to be submitted to the department by March  thirty-first,  two  thousand eleven,  and  shall  be  subsequently revised to reflect each hospital's submission of a fully completed two thousand nine disproportionate share hospital data collection tool, which is required to be submitted to  the department by October first, two thousand eleven.   For  calendar  years  on  and  after two thousand twelve, such initial determinations shall reflect submission  of  data  as  required  by  the commissioner  on a specified date. All such initial determinations shall subsequently  be  revised  to  reflect  actual  rate  period  data   and statistics.  Indigent care payments will be withheld in instances when a hospital has  not  submitted  required  information  by  the  due  dates prescribed  in  this  paragraph,  provided,  however, that such payments shall be made upon submission of such required  data.  For  purposes  of calculations   pursuant   to   paragraph  (d)  of  this  subdivision  of eligibility to receive disproportionate share payments for a  rate  year or  part  thereof,  the  hospital  inpatient  utilization  rate shall be determined based on the base year  statistics  in  accordance  with  the methodology  established  by  the  commissioner,  and  costs incurred of furnishing hospital services shall be determined in  accordance  with  a methodology established by the commissioner consistent with requirements of  the  secretary  of  the  department of health and human services for  purposes of federal financial participation pursuant to the title XIX of the federal social security act in disproportionate share payments.  (f) The commissioner may recover any amounts paid in excess of maximum permissible  distributions  and  adjustments determined pursuant to this subdivision by retroactive adjustment and recoupment from payments  made for  beneficiaries  eligible  for  payments  pursuant to title eleven of article five of the social services law.  (g) Notwithstanding any inconsistent provision  of  this  subdivision, the provision of subparagraph (iii) of paragraph (b), subparagraph (iii) of  paragraph  (c)  or  subparagraph  (ii)  of  paragraph  (d)  of  this subdivision shall be of no force and effect and shall be deemed to  have been  null and void as of January first, nineteen hundred ninety-four in the event the secretary of the department of health and  human  services determines  that  distributions  based on such provisions would render a health care related tax on general  hospitals  an  impermissible  health care  related  tax  for  purposes  of  the  federal  medicaid  voluntary contribution and provider specific tax amendments  of  nineteen  hundred ninety-one  for  purposes  of  such  health  care  related  tax receipts reducing the amount deemed expended by the state as  medical  assistance for purposes of federal financial participation.   22.  Undistributed  funds.  Any  funds, including income from invested funds, remaining in the bad debt and charity care and capital  statewide pool  after distributions in accordance with paragraphs (a), (b), (b-1), (c), (d), (e) and (f) of subdivision nineteen of this section  shall  be distributed proportionately to voluntary non-profit, private proprietary and  public general hospitals, excluding major public general hospitals, on the basis of hospital specific assessments submitted to the pool.   23. Reimbursement  rates.  The  assessments  pursuant  to  subdivision eighteen  of  this  section  shall  not  be  an  allowable  cost  in the determination of  general  hospital  inpatient  reimbursement  rates  in accordance  with  this section and section twenty-eight hundred seven of this article.   24. Federal financial participation. The council may adopt  rules  and regulations,  subject  to  the  approval  of the commissioner, to adjust rates of payment by governmental agencies for general hospital inpatient services determined in accordance with this section as necessary to meet federal  requirements  for  securing  federal  financial   participation pursuant  to  title  XIX of the federal social security act in the event the state cannot provide assurances satisfactory  to  the  secretary  of health and human services related to a comparison of rates of payment in the  aggregate  to  maximum  aggregate payments determined in accordance with federal law and regulation which are substantially the same as such assurances as  in  effect  on  October  twenty-sixth,  nineteen  hundred eighty-seven   for   securing   such  federal  financial  participation. Notwithstanding any other law, the state reserves the  right  to  recoup any  payments  by  governmental  agencies for general hospital inpatient services  authorized  by  this  section  for  which  federal   financial participation  has  been denied in connection with that determination by the department of health and human services.   25. Medical education expenses. (a) Notwithstanding  any  inconsistent provision  of  this  section,  to encourage the training of more primary care physicians, for annual rate periods beginning on or  after  January first, nineteen hundred ninety-two, indirect medical education expenses, as defined in subparagraph (ii) of paragraph (c) of subdivision seven of this section, of a general hospital included in the determination of the operating cost component of general hospital rates of payment for a rate period  in accordance with subdivisions six and seven of this section or in accordance with paragraph (e), (g) or (i) of subdivision four of this  section for general hospitals or distinct units of general hospitals not reimbursed on the basis of case based payments per  discharge  shall  be adjusted to reflect the following modifications:  (i)  the  calculation  of  interns  and  residents  to  bed ratios for purposes of determining indirect reimbursement shall  include  residents in  non-hospital  ambulatory  settings. The sum in total for all general hospitals of the indirect medical education expenses shall equal the sum in total for each general hospital determined as if  the  provisions  of this   section  were  applied  without  consideration  of  residents  in non-hospital ambulatory settings; and  (ii) for annual rate periods beginning  on  or  after  January  first, nineteen  hundred  ninety-two,  residencies shall be weighted to provide higher weights for  primary  care  and  emergency  medicine  physicians. Primary  care  residents  specialties  shall  include  family  medicine, general pediatrics, primary care  internal  medicine  and  primary  care obstetrics  and  gynecology.  In  determining  whether a residency is in primary care, the commissioner shall consult with  the  New  York  state council  on graduate medical education and the state hospital review and planning council. Reimbursable indirect expenses of medical education of a general hospital  for  a  rate  period  shall  be  weighted  based  on projected  medical  education  statistics  for such general hospital for such rate period, and subsequently reconciled through appropriate  audit procedures  to actual statistics by a prospective adjustment to rates of payment. The weighting factors shall be  determined  based  on  nineteen hundred   ninety   data  and  statistics  and  shall  include  residents identified in subparagraph (i) of this paragraph not previously included in such calculations  such  that  the  sum  in  total  for  all  general hospitals  of  the  results  of  the weighting factors multiplied by the indirect medical education expenses  for  each  general  hospital  shall equal,  approximately, the sum in total for all general hospitals of the indirect medical education expenses for each general hospital determined as if the provisions of this section were applied without  consideration of  the  weighting  factors  or  residents  in  non-hospital  ambulatory settings determined pursuant to this subdivision. Residency positions in any specialty shall be weighted to equal no  less  than  nine-tenths  of what such position would have equaled if reimbursement were to have been calculated  without  regard  to  the  weighting  factors.  If  a general hospital is reimbursed by this provision in excess of  the  amount  such hospital  would  have  been  reimbursed  without regard to the weighting factors, such general hospital shall  apply  such  additional  funds  to encourage  the  training  of  primary care physicians. The provisions of this subparagraph shall not apply to those four specialty eye  and  ear, special surgery and orthopedic and joint disease hospitals, specified by the  commissioner,  whose  primary  mission  is  to  engage in research, training, and clinical care in the above-named areas.  (b) Hospitals  shall  furnish  to  the  department  such  reports  and information  as  may be required by the commissioner to assess the cost, quality and health system needs for medical education provided.  (c) For purposes  of  determining  how  such  weighting  factors  have resulted  in  the  increased  training  of  physicians  in  primary care specialties, the council on graduate medical education shall  prepare  a report  on  or  before March thirty-first, nineteen hundred ninety-five. Such report shall include, but shall not be limited to: an evaluation of the effectiveness such weighting factors  have  had  on  the  number  of residents  matched in primary care specialties; the degree to which such weighting factors have impacted  general  hospitals  to  redirect  their residency  programs  toward  training  primary  care physicians; and the impact such weighting factors have had  on  graduate  medical  education  within general hospitals. Such report shall also include recommendations to  the  governor and the legislature on the continuation, expiration or modification of such weighting factors.  (d)  Notwithstanding  any  inconsistent  provision of this section and subject to the availability of federal financial participation:  (i) For periods on and after  April  first,  two  thousand  four,  the commissioner  shall adjust inpatient medical assistance rates of payment established pursuant  to  this  section,  including  discrete  rates  of payment  calculated  pursuant to paragraph a-three of subdivision one of this section, for non-public general hospitals, and for periods  on  and after April first, two thousand seven, for public and non-public general hospitals,  in  accordance with subparagraph (ii) of this paragraph, for purposes of reimbursing graduate medical education costs  based  on  the following methodology:  (ii)  Rate adjustments for each general hospital shall be based on the difference between the graduate medical education component, direct  and indirect,  of  the two thousand three medical assistance inpatient rates of payment, including exempt unit per diem rates,  and  an  estimate  of what  the  graduate medical education component, direct and indirect, of such medical assistance inpatient rates  of  payment,  including  exempt unit  per  diem  rates would be, stated at two thousand three levels and calculated as follows:  (A) Each general hospital's total direct medical  education  costs  as reported  in the two thousand one institutional cost report submitted as of December thirty-first, two thousand three, and  (B) An estimate of the total indirect medical education costs for  two thousand  one  calculated  in accordance with the methodology applicable for purposes of determining an estimate of  indirect  medical  education costs  pursuant  to  subparagraph  (ii)  of paragraph (c) of subdivision seven of this section. The indirect medical education costs shall  equal the  product  of  two thousand one hospital specific inpatient operating costs, including exempt unit  costs,  and  the  indirect  teaching  cost percentage determined by the following formula:           1-(1/(1+1.89(((1+r)^.405)-1))) where  r  equals  the  ratio  of  residents  and fellows to beds for two thousand one adjusted  to  reflect  the  projected  two  thousand  three resident counts.  (C)  Each  hospital's rate adjustment shall be limited to seventy-five percent of the graduate medical education component included in its  two thousand  three medical assistance inpatient rates of payment, including exempt unit rates. For periods on and after April  first,  two  thousand seven,  the seventy-five percent limit shall not apply to rate decreases calculated pursuant to this paragraph.  (D) For the period  April  first,  two  thousand  four  through  March thirty-first,  two  thousand  seven,  no  hospital  shall receive a rate adjustment pursuant to this paragraph if such rate adjustment would be a negative amount. For periods on and  after  April  first,  two  thousand seven,  no  public  general  hospital  shall  receive  a  rate  increase calculated pursuant to this paragraph.  (iii) If the aggregate amount of rate adjustments calculated  pursuant to this paragraph exceeds the upper payment limit calculated pursuant to federal   regulations,   such   rate   adjustments   shall   be  reduced proportionally by the amount in excess  of  the  federal  upper  payment limit.  Such  reduction, if applicable, shall be calculated on an annual basis.  (iv) Such rate adjustment shall be included as an  add-on  to  medical assistance  inpatient rates of payment, excluding exempt unit rates, but including inpatient rates of  payment  established  in  accordance  with  paragraph  a-three  of subdivision one of this section. Such rate add-on shall be based on medical assistance data reported  in  each  hospital's annual  cost report submitted for the period two years prior to the rate year  and  filed with the department by November first of the year prior to the rate year. Such  amounts  shall  not  be  reconciled  to  reflect changes  in  medical  assistance  utilization between the year two years prior to the rate year and the rate year.  (e) From amounts available pursuant to paragraph (oo)  of  subdivision one of section twenty-eight hundred seven-v of this article, allocations shall   be  made  to  non-public  general  hospitals  receiving  a  rate adjustment pursuant to paragraph (d) of this subdivision when  the  rate adjustment  pursuant to paragraph (d) of this subdivision results in the general hospital exceeding its applicable disproportionate share payment limit in the year in which the adjustment is made and the amount of  the associated  reduction  in the hospital's disproportionate share payments would result in the hospital receiving less than its total  distribution amount  in  that year. A hospital's "total distribution amount" shall be the amount that the hospital would have received pursuant to  paragraphs (c) and (d) of subdivision three of section twenty-eight hundred seven-m of  this  article  prior  to  the  effective  date  of this paragraph. A hospital's eligible loss for purposes of this  paragraph  shall  be  the amount  of  the  loss  in  such total distribution amount. Each eligible hospital's allocation of available  funds  pursuant  to  this  paragraph within  a  year  shall be determined based on its proportionate share of the aggregate eligible losses for all such  hospitals,  limited  by  the amount  of  the  rate  adjustment  pursuant  to  paragraph  (d)  of this subdivision.   26.  Disproportionate  share  payments.   Distributions   to   general hospitals  from  bad  debt  and  charity care regional pools pursuant to subdivision  seventeen  of  this  section,  distributions   to   general hospitals  from the bad debt and charity care and capital statewide pool pursuant to paragraphs (c) and  (d)  of  subdivision  nineteen  of  this section,  distributions  to  general  hospitals  from  the  bad debt and charity  care  for  financially  distressed  hospitals  statewide   pool pursuant  to  subdivision  fourteen-c of this section and the adjustment provided in accordance with subdivision fourteen-a of this  section  and the  adjustment  provided  in  accordance with subdivision fourteen-d of this section shall be considered  disproportionate  share  payments  for inpatient   hospital   services   to   general   hospitals   serving   a disproportionate number of low income patients with  special  needs  for purposes  of  providing  assurances to the secretary of health and human services as necessary to meet federal requirements for securing  federal financial  participation  pursuant  to  title  XIX of the federal social security act.   27. Reports. (a) The commissioner of health shall submit a  report  to the  legislature  and  the council on health care financing on or before February first, nineteen hundred eighty-eight detailing  the  objective, impact,  design  and  computation for an inpatient pricing component. In terms of the design and computation for a  pricing  system  such  report shall  include  but not be limited to: a description and methodology for developing  peer  groups,  identification  of  costs  included  in   the calculation  of  a group average and any adjustments made to such costs, the  methodology  developed  to  reflect  outliers,  any   teaching   or disproportionate  share  adjustments  made,  the calculation of wage and power equalization factors, and identification of any  adjustments  made to  the service intensity weights or diagnosis-related group categories. The commissioner  shall  explore  methodologies  for  the  inclusion  of severity  of  illness  considerations in determining group average costs  and rates and shall include all details of his analysis  in  the  report required under this subparagraph. If it is determined that a severity of illness   adjustment  cannot  be  developed  for  incorporation  in  the computations,  the  report  filed shall include the specific reasons for this conclusion. With regard to a fiscal  impact  analysis  such  report shall include but not be limited to the impact on major types of general hospitals   including  rural,  urban,  teaching,  non-teaching,  plus  a regional analysis; and should indicate any characteristics which can  be observed  regarding  general  hospitals  which  would  be  significantly impacted by the introduction of a pricing  component.  The  commissioner shall  expeditiously make available for inspection by interested parties pertinent  data  used  in  the  development  of  the  inpatient  pricing component  consistent  with  appropriate  department  procedures for the release and protection of confidential data.  (b) The commissioner shall submit a report to  the  governor  and  the legislature  on  or  before February first, nineteen hundred ninety-five regarding the objective, impact, design and implementation of  the  case based   payment   system   for  inpatient  hospital  services  based  on diagnosis-related groups created pursuant to this section including,  in particular, an analysis of the group price component of case based rates of  payment  and the appropriateness and effectiveness of the provisions relating to financing of uncompensated care. The reports  shall  include but not be limited to a fiscal impact analysis of the impact of the case based  payment  system  on  major  types  of general hospitals including rural, urban, teaching and non-teaching, plus a regional analysis.  Such reports  shall  evaluate  the impact of the case based payment system on general hospital inpatient medical and clinical care and the quality  of hospital  services.  The  reports shall also include recommendations for continuation or modification  of  the  case  based  payment  system  for inpatient hospital services provided on or after January first, nineteen hundred ninety-six.   ** (c)   The  commissioner  shall  report  to  the  governor  and  the legislature on or before December first, nineteen  hundred  eighty-eight with  a plan relating to the structure and financing of graduate medical education.  Such plan shall include an evaluation of and recommendations for graduate medical education with respect to health services  delivery and  educational  goals  including  but  not  limited  to the following: appropriate  supply  and  distribution  of  primary  care  providers  by geographic area; adequate supply and distribution of medical specialists according  to  projected  population  needs;  educational  opportunities representative of current and future practice settings;  the  impact  of such  plan  on  health  care delivery in currently underserved and rural areas; and  reimbursement  changes  to  effectuate  the  recommendations included  in  the  plan.  Such  plan shall be developed with substantial participation by the  department  of  education,  the  medical  schools, residency  training  programs,  health  systems  agencies,  health  care institutions, and physicians.   ** NB Inadvertently omitted from 731/93 amendment   * 28. Notwithstanding any inconsistent provision of this section:  (a) the commissioner may adjust, on  a  per  unit  of  service  basis, general   hospital  inpatient  services  rates  of  payment  established pursuant  to  this  section  as  in  effect  on  and   before   December thirty-first, nineteen hundred ninety-six prospectively as an additional factor to be paid, including the impact of payment differentials as were in  effect  pursuant  to this section, in addition to, or as a reduction to, any hospital charges or negotiated rate (the adjustment may  not  be negotiated by the payor); including, but not limited to, capital related inpatient  expenses  reconciliation  adjustments pursuant to subdivision  eight of this section, rate adjustments  for  corrections,  appeals  and volume  changes  pursuant  to  subdivision  nine  of  this section, rate adjustments to reflect trend factor adjustments pursuant to  subdivision ten  of  this  section,  maximum case mix change adjustments pursuant to paragraph (f) of subdivision eleven of  this  section,  and  adjustments based on audits;  (b) the allowances percentages established pursuant to this article in effect  for  a  rate  period  shall  be  applied  to hospital charges or negotiated rates plus the prospectively adjusted  payment  of  rates  of payment  of  a general hospital in accordance with paragraph (a) of this subdivision;  (c) no recalculation of the  basis  for  distribution  of  funds  from regional  or  statewide pools established pursuant to this section shall be made based on the impact of a  prospective  adjustment  to  rates  of payment authorized pursuant to this subdivision; and  (d)   prospective   rate   adjustments  authorized  pursuant  to  this subdivision for a general  hospital  based  on  appeals  approved  after January  first, nineteen hundred ninety-eight shall be included in rates of payment as a one hundred percent  facility  specific  adjustment  and shall not affect the calculation of the group category average inpatient reimbursable  operating cost per discharge for such retrospective period for any other general hospital.   * NB Expires December 31, 2023   * 29. Coinsurance and deductibles. (a) If a  general  hospital  and  a third-party payor agree to a negotiated payment methodology for a period on  or  after January first, nineteen hundred ninety-seven that is based on a discount from hospital charges, such discount shall  apply  to  the calculation  of  the charge basis for deductible and coinsurance amounts for such period owed for any patient covered by such  third-party  payor as the primary payor.  (b)  If  a  general  hospital  and  a  third-party  payor  agree  to a negotiated payment methodology for a period on or after  January  first, nineteen  hundred  ninety-seven  that  is  not  based on a discount from hospital charges, excluding capitation arrangements, the maximum  amount to be charged for deductible and coinsurance amounts for such period for any patient covered by such third-party payor as the primary payor shall not  exceed  the  amount  calculated  by  applying  the  deductible  and coinsurance amounts to the amount due on the basis  of  such  negotiated payment arrangement.   * NB Expires December 31, 2023   30. General hospital recruitment and retention of health care workers. Notwithstanding  any  inconsistent provision of this section and subject to the availability of federal financial participation:  (a) (i) The commissioner shall  adjust  inpatient  medical  assistance rates  of  payment  established  pursuant to this section for non-public general hospitals in accordance with subparagraph (ii) of this paragraph for purposes of recruitment and retention of health care workers in  the following aggregate amounts for the following periods:  (A) ninety-three million two hundred thousand dollars on an annualized basis  for  the  period  April  first, two thousand two through December thirty-first, two thousand two; one hundred eighty-seven  million  eight hundred  thousand  dollars on an annualized basis for the period January first, two thousand three through December  thirty-first,  two  thousand three;  two hundred sixty-two million one hundred thousand dollars on an annualized basis for the period January first, two thousand four through December thirty-first, two thousand six; one hundred thirty-one  million one  hundred thousand dollars for the period January first, two thousand seven through June  thirtieth,  two  thousand  seven,  and  two  hundred  forty-three  million  five  hundred thousand dollars for the period July first, two thousand  seven  through  March  thirty-first,  two  thousand eight, two hundred forty-three million five hundred thousand dollars for the  period  April first, two thousand eight through March thirty-first, two  thousand  nine;  one  hundred  sixty-three  million   one   hundred forty-five  thousand  dollars  for  the period April first, two thousand nine through November thirtieth, two thousand nine.  (ii) Such increases shall be allocated proportionally  based  on  each non-public  general  hospital's  reported  total gross salary and fringe benefit costs as reported on exhibit 11 of the 1999  institutional  cost report  submitted as of November first, two thousand one to the total of such reported costs for  all  non-public  general  hospitals,  provided, however,  that  for periods on and after July first, two thousand seven, fifty percent of such increases shall be allocated proportionally, based on each non-public hospital's reported total  gross  salary  and  fringe benefit  costs,  as  reported  on  exhibit  11  of  the nineteen hundred ninety-nine institutional cost report as  submitted  to  the  department prior to November first, two thousand one, to the total of such reported costs  for  all  non-public general hospitals, and fifty percent of such increases  shall  be  allocated  proportionally,  based  on  each   such hospital's  total reported medicaid inpatient discharges, as reported in the two thousand four institutional cost  report  as  submitted  to  the department  prior  to  November first, two thousand six, to the total of such reported medicaid inpatient discharges for all  non-public  general hospitals,  as  weighted proportionally to reflect the relative medicaid case mix of each such hospital. These amounts shall  be  included  as  a reimbursable  cost  add-on  to  medical  assistance  inpatient  rates of payment established pursuant to  this  section  for  non-public  general hospitals   based   on  medical  assistance  utilization  data  in  each hospital's annual cost report submitted two  years  prior  to  the  rate year.  Such  amounts  shall  be reconciled to reflect changes in medical assistance utilization between the year two years prior to the rate year and the rate year based on data reported in each hospital's cost  report for  the  respective  rate  year.  These  amounts shall be included as a reimbursable cost  add-on  to  medical  assistance  inpatient  rates  of payment  established  pursuant  to  this  section for non-public general hospitals  based  on  medical  assistance  utilization  data   in   each facility's  annual  cost  report  submitted  two years prior to the rate year. For rate adjustments effective May first, two  thousand  five  and thereafter  such  amounts  shall  be  reconciled  to  reflect changes in medical assistance utilization between the year two years prior  to  the rate  year and the rate year based upon data reported in each hospital's institutional cost report for the respective rate year.  (b) (i) Notwithstanding sections one hundred twelve  and  one  hundred sixty-three  of  the  state  finance  law  and  any  other  inconsistent provision of law, the commissioner shall make grants to  public  general hospitals  without a competitive bid or request for proposal process for purposes of recruitment and retention of  health  care  workers  in  the following aggregate amounts for the following periods:  (A)  eighteen  million  five hundred thousand dollars on an annualized basis for the period April first,  two  thousand  two  through  December thirty-first,  two  thousand  two;  thirty-seven  million  four  hundred thousand dollars on an annualized basis for the  period  January  first, two  thousand  three  through December thirty-first, two thousand three; fifty-two million two hundred thousand dollars on  an  annualized  basis for  the  period  January  first,  two  thousand  four  through December thirty-first, two thousand six; twenty-six million one hundred  thousand dollars  for  the  period January first, two thousand seven through June  thirtieth, two thousand seven, forty-nine million dollars for the period July first, two thousand seven through March thirty-first, two  thousand eight,  and  forty-nine  million dollars for the period April first, two thousand eight through March thirty-first, two thousand nine.  (ii)  Such  grants  shall  be  allocated  proportionally based on each public general hospital's reported total gross salary and fringe benefit costs as reported on exhibit 11 of the 1999  institutional  cost  report submitted  as  of  November first, two thousand one to the total of such reported costs for all public general hospitals.  (c) From amounts available pursuant to paragraph (gg)  of  subdivision one of section twenty-eight hundred seven-v of this article, allocations shall  be  made  to  non-public  general hospitals whose allocated labor adjustments pursuant to paragraphs (a) and (e) of this  subdivision  and adjustment pursuant to subdivision thirty-two of this section results in the  general  hospital  exceeding  its applicable disproportionate share payment limit.  Each  such  hospital's  allocation  of  available  funds pursuant  to  this  paragraph within a year shall be determined based on its  proportionate  share  of  the  aggregate   reduction   of   federal disproportionate  share  funding  for  all  such  hospitals for the year resulting from the allocated labor adjustments  pursuant  to  paragraphs (a)  and  (e)  of  this  subdivision and from the adjustment pursuant to subdivision thirty-two of this section.  (d) General hospitals which  have  their  rates  adjusted  or  receive grants   pursuant  to  paragraphs  (a)  and  (b)  of  this  subdivision, respectively, shall use such funds for the purpose  of  recruitment  and retention  of  non-supervisory  workers at health care facilities or any worker with direct patient care responsibility and are  prohibited  from using such funds for any other purpose. Funds under this subdivision are not  intended  to  supplant support provided by a local government. Each such general hospital shall submit, at a time and  in  a  manner  to  be determined  by  the commissioner, a written certification attesting that such funds will be used  solely  for  the  purpose  of  recruitment  and retention  of  non-supervisory  workers at health care facilities or any worker with direct patient  care  responsibility.  The  commissioner  is authorized  to audit each general hospital to ensure compliance with the written certification required by this paragraph and  shall  recoup  any funds  determined  to have been used for purposes other than recruitment and retention of non-supervisory workers at health  care  facilities  or any  worker  with  direct  patient  care responsibility. Such recoupment shall be in addition to applicable penalties under sections  twelve  and twelve-b of this chapter.  (e)(i)  The  commissioner  shall  adjust  inpatient medical assistance rates of payment  established  pursuant  to  this  section  for  general hospitals  in  accordance  with  subparagraph (ii) of this paragraph and shall  establish  discrete  rates  of  payment  for  such  hospitals  in accordance  with  subparagraph  (iii) of this paragraph, for purposes of additional support of recruitment and retention of health  care  workers in the following aggregate amounts for the following periods:  (A)  one  hundred twenty-one million dollars for the period May first, two thousand five through December thirty-first, two thousand  five  and one hundred twenty-one million dollars for the period January first, two thousand six through December thirty-first, two thousand six.  (ii)  Such  increases  shall be allocated proportionally based on each general hospital's reported gross salary and  fringe  benefit  costs  as reported  on  exhibit 11 of the 1999 institutional cost report submitted as of November first, two thousand one to the  total  of  such  reported costs  for  all  general hospitals. These amounts shall be included as a reimbursable cost  add-on  to  medical  assistance  inpatient  rates  of  payment established pursuant to this section for general hospitals based on  medical  assistance  utilization data in each facility's annual cost report submitted two years prior to the rate year. Such amounts shall be reconciled  to reflect changes in medical assistance utilization between the year two years prior to the rate year and the rate year  based  upon data  reported  in  each  hospital's  institutional  cost report for the respective rate year.  (iii) The commissioner shall establish, subject to the approval of the director of the budget, discrete rates of payment for general  hospitals for  payments  under  the  medical assistance program pursuant to titles eleven and eleven-D of article five  of  the  social  services  law  for persons  eligible  for medical assistance and family health plus who are enrolled in health maintenance organizations based  on  the  calculation set  forth  in  subparagraph  (ii)  of  this  paragraph for such general hospitals. If discrete rates of payment under this subparagraph are  not established,  the  commissioner shall adjust the calculation established pursuant to subparagraph (ii) of this paragraph to account  for  medical assistance  utilization  described  under  this  subparagraph  for  such non-public general hospital.  (iv) Payment of  the  non-federal  share  of  the  medical  assistance payments  made pursuant to this paragraph shall be the responsibility of the state and shall not include a local share. Payments made pursuant to this paragraph or pursuant to paragraph (a) of this subdivision  may  be added  to  rates  of  payment  or made as aggregate payments to eligible general hospitals.  (f) In the event that a hospital entitled to an adjustment pursuant to paragraph (a) or (e) of this subdivision closes or otherwise experiences a change in status that eliminates its ability to  continue  to  receive such  adjustments, the commissioner shall allocate the amount determined under subparagraph (ii)  of  paragraph  (a)  and  subparagraph  (ii)  of paragraph  (e) of this subdivision for such hospital to hospitals in the immediate region of  the  closing  hospital  based  upon  the  remaining hospitals' reported gross salary and fringe benefit costs as reported on exhibit  eleven  of  the  two  thousand  four  institutional cost report submitted as of November first, two thousand five to the total  of  such reported  costs  for  all  general  hospitals  in  the region, provided, however, that for periods on and after July first, two  thousand  seven, such  allocations  shall  be based on such remaining hospitals' reported medicaid inpatient discharges, as reported  in  the  two  thousand  four institutional  cost report submitted to the department prior to November first, two  thousand  six,  to  the  total  of  such  reported  medicaid inpatient  discharges for all such remaining hospitals. The commissioner shall define the immediate region as the county or counties within which workers  displaced  from  the  closing  hospital  are  likely  to   seek re-employment.   31.   Supplemental   general   hospital   recruitment   and  retention adjustment.   (a) Notwithstanding any law, rule  or  regulation  to  the contrary,  the  commissioner  shall,  within  amounts  appropriated, and contingent on the availability of federal financial participation,  make Medicaid  rate  adjustments  for non-public general hospitals to address extraordinary  costs  associated  with  recruitment  and  retention   of non-supervisory  workers  at  health  care facilities or any worker with direct patient care responsibility at such general  hospitals.  Eligible hospitals   shall   be  selected  by  the  commissioner  pursuant  to  a competitive process. Requests for proposals for eligible projects  shall be issued by the commissioner.  (b) Such eligible projects may include:  (i)  an  increase  in  non-supervisory  staff, either facility wide or targeted at a particular area of care or shift;  (ii)  increased  training  and  education  of  non-supervisory  staff, including allowing non-supervisory staff  to  increase  their  level  of licensure relevant to general hospital care;  (iii) efforts to decrease staff turn-over; and  (iv)  other  efforts  related  to  the  recruitment  and  retention of non-supervisory  staff  or  any  worker   with   direct   patient   care responsibility that will affect the quality of care at such facility.  (c)  The  commissioner shall consider, in selecting eligible projects, the likelihood that such project will provide needed resources  to  meet legal  commitments  for increased labor costs, the financial need of the facility, the existence of a shortage of qualified hospital  workers  in the  geographic  area in which the facility is located, the existence of high employee turn-over at the facility and such other  matters  as  the commissioner deems appropriate.  (d)   In   implementing   rate   adjustments   authorized  under  this subdivision, the commissioner shall establish, subject to  the  approval of  the director of the budget, discrete rates of payment for non-public general hospitals for payments  under  the  medical  assistance  program pursuant  to  titles  eleven  and eleven-D of article five of the social services law for persons eligible  for  medical  assistance  and  family health plus who are enrolled in health maintenance organizations.  (e)  Adjustments  to  Medicaid  rates of payment made pursuant to this section shall not be subject to subsequent adjustment or reconciliation.  (f) Adjustments to Medicaid rates of payment  made  pursuant  to  this section  shall not, in aggregate, exceed fifteen million dollars for the period beginning April first,  two  thousand  two  and  ending  December thirty-first,  two  thousand  two  and, on an annualized basis, for each annual period thereafter beginning January first, two thousand three and ending December thirty-first,  two  thousand  six,  and  shall  not,  in aggregate,  exceed  seven  million five hundred thousand dollars for the period January first, two thousand seven  through  June  thirtieth,  two thousand seven.   32.  Rural  hospital supplemental rate adjustment. Notwithstanding any inconsistent provision of this section:  (a) The commissioner shall adjust inpatient medical  assistance  rates of  payment  established pursuant to this section for rural hospitals as defined in paragraph (c) of  subdivision  one  of  section  twenty-eight hundred seven-w of this article in accordance with paragraph (b) of this subdivision  for  purposes  of  supporting critically needed health care services in rural areas in  the  following  aggregate  amounts  for  the following periods:   seven  million  dollars  for  the  period May first, two thousand five through December thirty-first, two thousand five, seven million  dollars for  the  period  January  first,  two  thousand  six  through  December thirty-first, two thousand six, seven million  dollars  for  the  period April  first,  two  thousand  seven  through  December thirty-first, two thousand seven, seven million dollars for  calendar  year  two  thousand eight,  and  six million four hundred seventeen thousand dollars for the period January first, two thousand nine through November thirtieth,  two thousand nine.  (b)  Such  increases  shall be allocated proportionately based on each such rural hospital's total reported medicaid  inpatient  discharges  as reported  in the two thousand two institutional cost report to the total of such discharges for all  rural  hospitals.  These  amounts  shall  be included  as  a reimbursable cost add-on to medical assistance inpatient rates  of  payment  established  pursuant  to  this  section  for  rural  hospitals   based   on  medical  assistance  utilization  data  in  each facility's annual cost report submitted two  years  prior  to  the  rate year.  Such  amounts  shall  be reconciled to reflect changes in medical assistance utilization between the year two years prior to the rate year and   the  rate  year  based  upon  data  reported  in  each  hospital's institutional cost report for the respective rate year.  (c) Payment  of  the  non-federal  share  of  the  medical  assistance payments  made  pursuant to this subdivision shall be the responsibility of the state and shall not include a local share. Payments made pursuant to this subdivision may  be  added  to  rates  of  payment  or  made  as aggregate payments to eligible general hospitals.   33. Notwithstanding any provision of law which is inconsistent with or contrary   to   the   structure  established  by  this  subdivision  and subdivision two-a of section twenty-eight hundred seven of this  article in  order to transition from nineteen hundred eighty-one base year costs to two  thousand  five  base  year  costs  by  no  later  than  December thirty-first,  two  thousand  twelve, and subject to the availability of federal financial participation, medicaid per  diem  and  per  discharge rates  of payment for general hospital inpatient services for discharges and days occurring on and after  December  first,  two  thousand  eight, shall be computed in accordance with the following:  (a)(i) for the period December first, two thousand eight through March thirty-first,  two  thousand  nine,  such  rates  shall  be subject to a uniform transition adjustment which  shall  be  based  on  each  general hospital's   proportional   share  of  projected  medicaid  reimbursable inpatient operating costs and result in an aggregate reduction  in  such rates  equal  to  fifty-one  million  five  hundred thousand dollars, as determined by the commissioner, provided, however, that such  transition adjustment  shall  not apply to rates computed pursuant to paragraph (1) of subdivision four of this section; and  (ii) for the period April  first,  two  thousand  nine  through  March thirty-first,  two thousand ten, such rates shall be revised pursuant to a chapter of the laws  of  two  thousand  nine  and  as  reflecting  the findings  and  recommendations of the commissioner as issued pursuant to the provisions of paragraph (b) of this subdivision, provided,  however, that  such  revisions shall reflect an aggregate reduction in such rates of no less than one hundred fifty-four  million  five  hundred  thousand dollars,  provided  further, however, that, notwithstanding any contrary provision of law, as determined by the commissioner, to the extent  that a  chapter  of the laws of two thousand nine is not enacted resulting in such  an  aggregate  annual  reduction  of  no  less  than  one  hundred fifty-four  million  five  hundred  thousand  dollars in such rates, the commissioner shall implement  a  uniform  reduction  of  such  rates  in accordance  with  the  methodology described in subparagraph (i) of this paragraph to the extent necessary, as determined by the commissioner, to achieve such an aggregate reduction in such rates for the  state  fiscal year beginning April first, two thousand nine and each state fiscal year thereafter; and  (iii)  for  the  periods  April  first, two thousand ten through March thirty-first, two thousand twelve, rates shall reflect prior  year  rate reductions  and  such additional reductions as are required to establish rates based on two  thousand  five  reported  allowable  Medicaid  costs pursuant to a chapter of the laws of two thousand ten.  (b)  In consultation with the chairs of the senate and assembly health committees, the commissioner shall, by no later  than  July  first,  two thousand  eight,  establish  a  technical  advisory  committee  for  the purposes of examining data and  evaluating  rate-setting  methodological issues,  including the impact on hospitals of different methodologies in  preparation for the phased transition to  the  utilization  of  reported allowable  two  thousand five operating costs for the purpose of setting inpatient rates of payment for periods on and  after  April  first,  two thousand nine, which phased transition shall be authorized in accordance with  a chapter of the laws of two thousand nine. The technical advisory committee  shall  consist   of   three   representatives   of   hospital associations,  two representatives of the health care industry and three representatives of community providers and consumers  as  determined  by the commissioner. By no later than August first, two thousand eight, the commissioner  shall  make  available to the technical advisory committee updated  data  and  documentation  relevant  to  the  projected   phased transition  to  utilization  of  reported  allowable  two  thousand five operating costs for rate-setting purposes. The issues to be examined  by the  technical  advisory committee shall include, but not be limited to, hospital  re-basing,  workforce  recruitment  and   retention   funding, graduate   medical   education   funding,   peer   group  pricing,  wage equalization factors, case mix and such other related  elements  of  the general hospital inpatient reimbursement system as deemed appropriate by the  commissioner.  The  technical advisory committee shall also examine the scope and volume of hospital out-patient services. By no later  than November first, two thousand eight the commissioner shall issue a report setting forth findings and recommendations, including divergent views of members  of  the  technical  advisory  committee  members concerning the matters examined by the technical advisory committee and  the  projected phased transition to utilization of two thousand five base year reported allowable  operating  costs for inpatient rates of payments on and after April first, two thousand nine.  (c) Paragraph (a) of this subdivision shall be effective the later of: (i) December first, two thousand  eight;  (ii)  after  the  commissioner receives  final  approval of federal financial participation in payments made for beneficiaries eligible for medical assistance under  title  XIX of  the federal social security act for the rate methodology established pursuant to subdivision two-a of section twenty-eight hundred  seven  of this  article;  or  (iii)  after  the  commissioner  determines that the department of health has the capability, for payments made  pursuant  to subdivision two-a of section twenty-eight hundred seven of this article, to  electronically receive and process claims and transmit payments with remittance  statements.  Prior  to  the  commissioner  making   such   a determination,  the  department  shall  provide training sessions on the rate methodology and  billing  requirements  for  services  pursuant  to subdivision  two-a of section twenty-eight hundred seven of this article and opportunity for hospitals to perform end-to-end  testing  on  claims submission, processing and payment.   34. Enhanced safety net hospital program. (a) For the purposes of this subdivision, "enhanced safety net hospital" shall mean a hospital which:  (i) in any of the previous three calendar years, has met the following criteria:  (A)  not  less  than  fifty  percent of the patients it treats receive medicaid or are medically uninsured;  (B) not less than  forty  percent  of  its  inpatient  discharges  are covered by medicaid;  (C)  twenty-five  percent  or  less  of  its  discharged  patients are commercially insured;  (D) not less than three percent of the patients it  provides  services to are attributed to the care of uninsured patients; and  (E)  provides  care  to  uninsured  patients  in  its  emergency room, hospital based  clinics  and  community  based  clinics,  including  the  provision  of  important  community  services,  such  as dental care and prenatal care;  (ii)  is  a public hospital operated by a county, municipality, public benefit corporation or the state university of New York;  (iii) is federally designated as a critical access hospital; or  (iv) is federally designated as a sole community hospital.  (b) Within amounts appropriated, the commissioner shall adjust medical assistance rates to enhanced safety net hospitals for  the  purposes  of supporting  critically  needed  health  care  services and to ensure the continued maintenance and operation of such hospitals.  (c) Payments made pursuant to this subdivision may be added  to  rates of payment or made as aggregate payments to eligible general hospitals.   35. Notwithstanding any inconsistent provision of this section, or any other  contrary  provision  of  law  and  subject to the availability of federal  financial  participation,  rates  of  payment  by  governmental agencies   for  general  hospital  inpatient  services  with  regard  to discharges occurring on and after  December  first,  two  thousand  nine shall be in accordance with the following:  (a)  For  periods  on  and after December first, two thousand nine the operating cost component of such rates of payments shall reflect the use of two thousand five operating costs as reported by each facility to the department prior to July first,  two  thousand  nine  and  as  otherwise computed in accordance with the provisions of this subdivision;  (b)  The commissioner shall promulgate regulations, and may promulgate emergency regulations, establishing methodologies for the computation of general hospital inpatient rates and such regulations shall include, but not be limited to, the following:  (i) The computation  of  a  case-mix  neutral  statewide  base  price, applicable  to  each rate period, but excluding adjustments for graduate medical education costs, high  cost  outlier  costs,  costs  related  to patient  transfers,  and other non-comparable costs as determined by the commissioner, such statewide base prices may be periodically adjusted to reflect changes in provider coding patterns and case-mix and such  other factors as may be determined by the commissioner;  (ii)  Only those two thousand five base year costs which relate to the cost of services provided to Medicaid inpatients, as determined  by  the applicable  ratio of costs to charges methodology, shall be utilized for rate-setting purposes, provided,  however,  that  the  commissioner  may utilize   updated   Medicaid  inpatient  related  base  year  costs  and statistics as necessary to adjust inpatient  rates  in  accordance  with clause (C) of subparagraph (x) of this paragraph;  (iii)  Such  rates  shall reflect the application of hospital specific wage equalization factors reflecting differences in wage rates;  (iv) Such rates shall reflect  the  utilization  of  the  all  patient refined  (APR) case mix methodology, utilizing diagnostic related groups with assigned weights that incorporate differing levels of  severity  of patient  condition  and  the associated risk of mortality, and as may be periodically updated by the commissioner;   * (iv-a) Effective April first, two thousand twenty,  such  rates  for public  general  hospitals  or  public  health systems, other than those operated by the state of New York or the state university of  New  York, located  in  a  city  having  a  population of one million or more shall include a rate add-on that reflects  reimbursement  for  costs,  to  the extent  permitted  under  42  CFR  447.272(b)(1)  and  based  on  actual utilization of services. Such  rate  add-on  shall  be  contingent  upon federal  financial  participation and approval, and subject to the terms of a binding memorandum of understanding executed between the department of health and the  public  general  hospital  or  public  health  system  receiving  the  rate add-on. If payment of such rate add-on is projected to cause Medicaid disbursements for such period to exceed the  projected department  of  health  Medicaid  state  funds  in  the  enacted  budget financial  plan pursuant to subdivision three of section twenty-three of the state finance law, as determined by the director of the  budget,  or memorandum  of  understanding  is  not  executed  or  is  breached,  the commissioner, in consultation with the director of  budget,  may  either cancel  or reduce payment of such rate add-on to achieve compliance with the enacted budget financial plan.   * NB Repealed March 31, 2023  (v) such  regulations  shall  incorporate  quality  related  measures, including,  but  not  limited  to, potentially preventable re-admissions (PPRs) and provide for rate adjustments or payment disallowances related to PPRs and other potentially  preventable  negative  outcomes  (PPNOs), which shall be calculated in accordance with methodologies as determined by the commissioner, provided, however, that such methodologies shall be based on a comparison of the actual and risk adjusted expected number of PPRs and other PPNOs in a given hospital and with benchmarks established by  the  commissioner and provided further that such rate adjustments or payment disallowances shall result in an aggregate reduction in Medicaid payments of no less than thirty-five million dollars for the period July first, two thousand ten through March thirty-first, two thousand  eleven and  no less than fifty-one million dollars for annual periods beginning April  first,  two  thousand  eleven  through  March  thirty-first,  two thousand  fifteen, provided further that such aggregate reductions shall be offset by Medicaid  payment  reductions  occurring  as  a  result  of decreased  PPRs  during  the period July first, two thousand ten through March thirty-first, two thousand eleven and the period April first,  two thousand  eleven through March thirty-first, two thousand fifteen and as a result of decreased PPNOs during the period April first, two  thousand eleven  through  March  thirty-first, two thousand fifteen; and provided further that for the period July first, two thousand ten  through  March thirty-first,  two  thousand  fifteen,  such rate adjustments or payment disallowances  shall  not  apply  to  behavioral  health  PPRs;  or   to readmissions  that  occur  on or after fifteen days following an initial admission. By  no  later  than  July  first,  two  thousand  eleven  the commissioner  shall enter into consultations with representatives of the health care facilities  subject  to  this  section  regarding  potential prospective  revisions  to  applicable  methodologies and benchmarks set forth in regulations issued pursuant to this subparagraph;  (vi) Such regulations shall address adjustments based on the costs  of high cost outlier patients;  (vii) Such rates shall continue to reflect trend factor adjustments as otherwise provided in paragraph (c) of subdivision ten of this section;  (viii)  Such  rates  shall  not  include  any  adjustments pursuant to subdivision nine of this section;  (ix) Rates for non-public, not for profit general hospitals which have not, as  of  the  effective  date  of  this  subdivision,  published  an ancillary  charges  schedule as provided in paragraph (j) of subdivision one of section twenty-eight hundred three of  this  article  shall  have their  inlier  payments  increased  by an amount equal to the average of cost outlier payments for comparable hospitals or by a methodology  that uses  a  statewide  or  regional  ratio  of  cost  to charges applied to statewide or regional comparable charges for those cases  determined  by the commissioner;  (x)  Such  regulations  shall provide for administrative rate appeals, but only with regard to: (A) the correction of computational  errors  or omissions  of  data,  including  with  regard  to  the hospital specific  computations pertaining to graduate medical education, wage equalization factor adjustments, (B) capital cost reimbursement, and, (C) changes  to the  base  year  statistics  and  costs used to determine the direct and indirect  graduate medical education components of the rates as a result of new teaching programs at new teaching hospitals and/or as a result of residents displaced and transferred as a  result  of  teaching  hospital closures;  (xi)  Rates for teaching general hospitals shall include reimbursement for direct and  indirect  graduate  medical  education  as  defined  and calculated  pursuant  to such regulations. In addition, such regulations shall specify the reports and information required by  the  commissioner to  assess  the  cost,  quality  and  health  system  needs  for medical education provided;  (xii)  Such  regulations  may  incorporate  quality  related  measures pertaining  to  the  inappropriate  use  of  certain medical procedures, including, but not limited  to,  cesarean  deliveries,  coronary  artery bypass grafts and percutaneous coronary interventions;  (xiii)   Such  regulations  may  impose  a  fee  on  general  hospital sufficient to cover the costs of auditing the institutional cost reports submitted by general hospitals, which shall be deposited in  the  Health Care Reform Act (HCRA) resources account.  (c)   The   base   period  reported  costs  and  statistics  used  for rate-setting  for  operating  cost  components,  including  the  weights assigned  to  diagnostic  related  groups,  shall  be  updated  no  less frequently than every four years and the new base  period  shall  be  no more  than  four  years  prior  to the first applicable rate period that utilizes such new base period provided, however, that the first  updated base  period shall begin on or after April first, two thousand fourteen, but no later than July first, two thousand fourteen.  (d) Capital cost reimbursement for general hospitals otherwise subject to the provisions of  this  subdivision  shall  remain  subject  to  the provisions of subdivision eight of this section.  (e)  The  provisions  of  this  subdivision  shall  not apply to those general hospitals or distinct units of general hospitals whose inpatient reimbursement does not, as of November  thirtieth,  two  thousand  nine, reflect   case  based  payment  per  diagnosis-related  group  or  whose inpatient reimbursement is, for periods on and  after  July  first,  two thousand  nine,  governed by the provisions of paragraphs (e-1) or (e-2) of subdivision four of this section.  (f)  Notwithstanding  section  one  hundred  twelve  or  one   hundred sixty-three  of  the  state  finance  law  or  any  other  law,  rule or regulation to the contrary, the commissioner may contract with a  vendor for    consideration    to    develop   the   specifications   for   the diagnosis-related groups methodology  as  provided  for  in  regulations promulgated  pursuant  to  paragraph  (b)  of  this  subdivision  if the commissioner certifies to the comptroller that such contract is  in  the best  interest of the health of the people of the state. Notwithstanding that such specifications shall be available pursuant to article  six  of the   public   officers   law,   such  contract  may  provide  that  the specifications for such adjusted or additional diagnosis-related  groups provided by the vendor shall be subject to copyright protection pursuant to federal copyright law.  (g)  Notwithstanding any inconsistent provision of this subdivision or any other contrary provision of law,  the  commissioner  may,  for  rate periods  on  and  after December first, two thousand nine and subject to the availability of federal  financial  participation,  make  additional adjustments  to  the  inpatient  rates  of  payment  of eligible general  hospitals,  to  facilitate  improvements  in  hospital  operations   and finances, in accordance with the following:  (i)  General  hospitals  eligible  for  distributions pursuant to this paragraph shall be those non public hospitals with  Medicaid  discharges equal to or greater than seventeen and one-half percent for two thousand seven.  (ii)  Funds  distributed pursuant to this paragraph shall be allocated to eligible hospitals pursuant to a formula such that, to the extent  of funds  available,  no hospital's reduction in Medicaid inpatient revenue as a result of the application of the provisions of paragraphs  (a)  and (b)  of this subdivision exceeds a percentage reduction as determined by the commissioner.  (iii) Funding pursuant to this paragraph shall be  available  for  the following periods and in the following amounts:  (A)  for  the  period  December first, two thousand nine through March thirty-first, two thousand ten, up to thirty-three million five  hundred thousand dollars;  (B)  for  the  period  April  first,  two  thousand  ten through March thirty-first, two thousand eleven, up to seventy-five  million  dollars, provided,  however,  that,  notwithstanding  subparagraph  (ii)  of this paragraph, no facility shall receive an amount pursuant to  this  clause that  is less than such facility received pursuant to clause (A) of this subparagraph;  (C) for the period April first,  two  thousand  eleven  through  March thirty-first, two thousand twelve, up to fifty million dollars;  (D)  for  the  period  April  first, two thousand twelve through March thirty-first, two thousand thirteen, up to twenty-five million dollars.  (iv) Payments made pursuant to this paragraph shall be added to  rates of   payments   and   not   be  subject  to  retroactive  adjustment  or reconciliation.  (v) Each hospital receiving funds pursuant to this paragraph shall, as a condition for eligibility for such funds, adopt a  resolution  of  the board  of  directors  of  each  such  hospital setting forth its current financial  condition  and  a  plan  for  reforming  and  improving  such financial condition, including ongoing board oversight, and shall, after two  years,  issue  a  report as adopted by each such board of directors setting  forth  what  progress  has   been   achieved   regarding   such improvement, provided, however, if such report is not issued and adopted by  each  such  board of directors, or if such report fails to set forth adequate progress, as determined by the commissioner,  the  commissioner may  deem such facility ineligible for further distributions pursuant to this paragraph and may redistribute such further distributions to  other eligible facilities in accordance with the provisions of this paragraph. The  commissioner  shall be provided with copies of all such resolutions and reports.  (h) Inpatient rate adjustments made pursuant to paragraphs (a) through (f) of this subdivision  after  application  of  adjustments  authorized pursuant  to  subdivision thirty-three of this section shall result in a net statewide decrease in aggregate Medicaid payments of  no  less  than seventy-five million dollars for the period December first, two thousand nine  through March thirty-first, two thousand ten, and no less than two hundred twenty-five million dollars for  the  period  April  first,  two thousand  ten  through  March thirty-first, two thousand eleven and each state fiscal year thereafter, provided, however,  that  such  reductions shall be in addition to the reductions required pursuant to subparagraph (ii) of paragraph (a) of subdivision thirty-three of this section.  (i) (i) Notwithstanding any inconsistent provision of this subdivision or  any  other contrary provision of law and subject to the availability  of federal financial participation,  for  the  period  July  first,  two thousand  ten  through March thirty-first, two thousand eleven, and each state  fiscal  year  period  thereafter,  the  commissioner  shall  make additional inpatient hospital payments up to the aggregate upper payment limit for inpatient hospital services after all other medical assistance payments, but not to exceed two hundred thirty-five million five hundred thousand  dollars  for  the  period July first, two thousand ten through March thirty-first, two thousand eleven, three hundred fourteen  million dollars  for  each state fiscal year beginning April first, two thousand eleven, through March thirty-first, two thousand thirteen, and  no  less than  three  hundred  thirty-nine  million dollars for each state fiscal year thereafter, to general hospitals, other than major  public  general hospitals,  providing  emergency  room services and including safety net hospitals, which shall, for the purpose of this paragraph, be defined as having either: a Medicaid share of total inpatient  hospital  discharges of  at  least  thirty-five  percent,  including both fee-for-service and managed care discharges for acute and exempt  services;  or  a  Medicaid share  of  total  discharges  of at least thirty percent, including both fee-for-service  and  managed  care  discharges  for  acute  and  exempt services,  and  also  providing  obstetrical  services.  Eligibility  to receive such additional payments shall be based on data from the  period two  years prior to the rate year, as reported on the institutional cost report submitted to the department as of October first of the prior rate year. Such payments shall be made as  medical  assistance  payments  for fee-for-service  inpatient hospital services pursuant to title eleven of article five of the  social  services  law  for  patients  eligible  for federal  financial  participation  under title XIX of the federal social security act and in accordance with the following:  (A) Thirty percent of such payments shall be allocated to  safety  net hospitals  based  on each eligible hospital's proportionate share of all eligible  safety  net  hospitals'  Medicaid  discharges  for   inpatient hospital  services,  including both Medicaid fee-for-service and managed care discharges for acute and exempt services, based on  data  from  the period   two   years  prior  to  the  rate  year,  as  reported  on  the institutional cost report submitted to  the  department  as  of  October first of the prior rate year;  (B)  Seventy  percent  of such payments shall be allocated to eligible general hospitals based on each such hospital's proportionate  share  of all  eligible  hospitals'  Medicaid  discharges  for  inpatient hospital services, including  both  Medicaid  fee-for-service  and  managed  care discharges  for acute and exempt services, based on data from the period two years prior to the rate year, as reported on the institutional  cost report submitted to the department as of October first of the prior rate year;  (C)  No  eligible general hospital's annual payment amount pursuant to this paragraph shall exceed the lower of the sum of the  annual  amounts due  that  hospital pursuant to section twenty-eight hundred seven-k and section twenty-eight hundred seven-w of this article; or the  hospital's facility  specific  projected  disproportionate  share  hospital payment ceiling established pursuant to federal  law,  provided,  however,  that payment amounts to eligible hospitals pursuant to clauses (A) and (B) of this  subparagraph in excess of the lower of such sum or payment ceiling shall be reallocated to eligible  hospitals  that  do  not  have  excess payment  amounts.  Such reallocations shall be proportional to each such hospital's aggregate payment amount pursuant to clauses (A) and  (B)  of this  subparagraph to the total of all payment amounts for such eligible hospitals;  (D) Subject to the availability of  federal  financial  participation, the  payment  methodology  set forth in this subparagraph may be further revised by the commissioner on an annual basis pursuant  to  regulations issued  pursuant  to  this  subdivision  for  periods on and after April first, two thousand eleven; and  (E) Subject to the availability of federal financial participation and in  conformance  with  all  applicable federal statutes and regulations, such payments shall  be  made  as  upper  payment  limit  payments  and, further,  such  payments  shall be made as aggregate monthly payments to eligible general hospitals.  (ii) In the  event  that  the  commissioner  determines  that  federal financial  participation  will  not  be available for aggregate payments made  in  accordance  with  clause  (E)  of  subparagraph  (i)  of  this paragraph, payments pursuant to this paragraph shall be included as rate add-ons  to  medical  assistance  inpatient rates of payment established pursuant to this subdivision based on data from  the  period  two  years prior  to  the  rate  year, as reported on the institutional cost report submitted to the department as of October first of the prior rate  year, provided,  however,  that if such payments are made as rate add-ons, the commissioner shall establish a procedure to reconcile payment amounts to reflect changes in medical assistance utilization from  the  period  two years  prior  to the rate year and the actual rate year based on data as reported on each hospital's annual institutional  cost  report  for  the respective rate year, as submitted to the department as of October first of the year following the rate year.  (iii)  Notwithstanding  any  other  law,  rule  or  regulation  to the contrary, projections of each general hospital's disproportionate  share limitations  as  computed  by  the  commissioner  pursuant to applicable regulations shall be adjusted to reflect any additional revenue received or anticipated to be received by each such general hospital pursuant  to this paragraph.  (j)  Notwithstanding  any  contrary  provision  of law, with regard to inpatient and outpatient Medicaid rates of payment for general  hospital services,  the  commissioner may make such adjustments to such rates and to the methodology for computing such rates as is necessary  to  achieve no  aggregate, net increase or decrease in overall Medicaid expenditures related to the implementation of  the  International  Classification  of Diseases  Version  10  (ICD-10) coding system on or about October first, two thousand fourteen, as compared to such aggregate  expenditures  from the twelve-month period immediately prior to such implementation.