NY Pub Health L § 2807-K (2021)
2021 New York Laws PBH - Public Health Article 28 - Hospitals 2807-K - General Hospital Indigent Care Pool.

§  2807-k.  General  hospital  indigent care pool. 1. Definitions. For purposes of this section, the following words or phrases shall have  the following meanings, unless the context otherwise requires:  (a)  "Major  public general hospital" means all state operated general hospitals, all general hospitals operated by the New  York  city  health and hospitals corporation as established by chapter one thousand sixteen of  the  laws  of  nineteen  hundred sixty-nine as amended and all other public general hospitals having  annual  inpatient  operating  costs  in excess of twenty-five million dollars.  (b)  "Nominal  payment  amount"  shall  mean  the  sum  of the dollars attributable  to  the  application  of   an   incrementally   increasing proportion  of  reimbursement  for percentage increases in targeted need according to a scale.  (c) "Targeted need" shall mean the relationship of uncompensated  care need  to  reported costs expressed as a percentage. Reported costs shall mean costs allocated  as  prescribed  by  the  commissioner  to  general hospital   inpatient   and   ambulatory   services,  excluding  referred ambulatory services. Targeted need shall be  determined  based  on  base year  data  and  statistics for the calendar year two years prior to the distribution period. Base year data and statistics for the calendar year two years prior to the distribution period shall  be  considered  final, for  purposes  of  this section, one hundred twenty days after hospitals receive the department's initial statewide rates for the same period  as the  distribution  period  and  shall  include any appropriate revisions reported by hospitals during such one hundred twenty days.  (d) "Uncompensated care need" means losses from bad debts  reduced  to cost  and  the costs of charity care of a general hospital for inpatient and ambulatory services, excluding  referred  ambulatory  services.  The cost  of  services  provided  as  an employment benefit or as a courtesy shall not be included.  (e) "Uninsured care" means losses from bad debts reduced to  cost  and the  costs  of  charity  care  of  a  general hospital for inpatient and ambulatory services, excluding referred ambulatory services,  which  are not  eligible  for payment in whole or in part by a governmental agency, insurer or other third-party payor on behalf  of  a  patient,  including payments  made directly to the general hospital and indemnity or similar payments made to the person who is a payor  of  hospital  services.  The cost  of  services  denied  reimbursement,  other  than  emergency  room services, for lack of medical necessity or lack of compliance with prior authorization requirements, or provided as an employment benefit, or  as a courtesy shall not be included.  (f)  "Ambulatory  services"  of  a  general  hospital  shall  mean all services delivered on an ambulatory basis, including, for periods on and after January first, two thousand four, services provided  at  qualified hospital-controlled diagnostic and treatment centers except as otherwise provided in subdivision thirteen of this section.  (g)  "Qualified  hospital-controlled  diagnostic and treatment center" shall mean a  voluntary,  non-profit  diagnostic  and  treatment  center providing  a comprehensive range of primary health care services that is controlling, controlled by, or  under  common  control  with  a  general hospital, and as of June thirtieth, two thousand three:  (i)   qualified  for  an  allocation  of  funds  pursuant  to  section twenty-eight hundred seven-p of this  article  or  pursuant  to  section seven  of  chapter  four  hundred  thirty-three  of the laws of nineteen hundred ninety-seven, as amended; or  (ii) the outpatient department  of  such  general  hospital  had  been designated  a federally-qualified health center under section 330 of the  Public Health Service Act (42 U.S.C. § 254b) and had directly received a grant under such section.   2.  To  the extent of funds appropriated therefor, funds shall be made available for distribution by or on behalf of the  state  in  accordance with  the  following  methodology,  as  payments under the state medical assistance program provided pursuant to title eleven of article five  of the  social  services  law,  from  a general hospital indigent care pool established by the commissioner.   3.  Each  major  public  general  hospital  shall  be  allocated   for distribution  from  the  pools  established pursuant to this section for each year through  December  thirty-first,  two  thousand  fourteen,  an amount  equal  to  the  amount  allocated  to  such major public general hospital from the regional  pool  established  pursuant  to  subdivision seventeen  of  section  twenty-eight hundred seven-c of this article for the period January first, nineteen hundred ninety-six  through  December thirty-first,  nineteen  hundred  ninety-six,  provided,  however,  that payments on and after January first, two thousand nine shall be  subject to the provisions of subdivision five-a of this section.   4.  (a)  From  funds  in  the  pool  for each year, thirty-six million dollars  shall  be  reserved  on  an  annual  basis   through   December thirty-first,  two  thousand  fourteen,  for  distribution  as high need adjustments  in  accordance  with  subdivision  six  of  this   section, provided,  however,  that  payments  on  and  after  January  first, two thousand nine shall be subject to the provisions of  subdivision  five-a of this section.  (a-1)  From  funds  in  the  pool  for each year, twenty-seven million dollars shall be reserved on an annual basis  for  the  periods  January first, two thousand through December thirty-first, two thousand ten, for distribution  in  accordance  with  subdivision sixteen of this section, provided, however,  that  payments  on  and  after  January  first,  two thousand  nine through December thirty-first, two thousand nine shall be subject to the provisions of subdivisions  five-a  and  five-b  of  this section, and shall be subject to the provisions of subdivision five-b of this section for periods on and after January first, two thousand ten.  (b)  The  balance  of funds in a pool not allocated in accordance with subdivision three of this section or reserved for distributions pursuant to subdivisions six and sixteen of this section shall be distributed  to eligible general hospitals, excluding major public general hospitals, on the  basis  of each general hospital's targeted need share, adjusted for transition factors in accordance with subdivision seven of this section.  (c) To  be  eligible  for  distributions  from  the  pool,  a  general hospital's targeted need must exceed one-half of one percent.  (d)  For  the  periods  January  first,  nineteen hundred ninety-seven through December thirty-first, nineteen  hundred  ninety-seven,  January first,  nineteen  hundred  ninety-eight  through  December thirty-first, nineteen hundred  ninety-eight,  and  January  first,  nineteen  hundred ninety-nine  through December thirty-first, nineteen hundred ninety-nine and on and after January first,  two  thousand,  each  eligible  general hospital's  targeted  need  share  shall  mean  the relationship of each general hospital's nominal payment amount  of  uncompensated  care  need determined in accordance with the scale specified in subdivision five of this  section  to the nominal payment amounts of uncompensated care need for all eligible general hospitals applied to  funds  available  in  the pool.   5.  The  scale  utilized  for  development  of  each  eligible general hospital's nominal payment amount shall be as follows:                                          Percentage of Reimbursement                                         Attributable to that Portion         Targeted Need Percentage            of Targeted Need               0     -.5%                          60%                .5+  -2%                           65%               2+    -3%                           70%               3+    -4%                           75%               4+    -5%                           80%               5+    -6%                           85%               6+    -7%                           90%               7+    -8%                           95%               8+                                 100%    5-a.  Notwithstanding  any  inconsistent  provision  of  this section, section twenty-eight hundred  seven-w  of  this  article  or  any  other contrary  provision  of  law,  subject  to  the  availability of federal financial participation and within amounts appropriated, for periods  on and after January first, two thousand nine, ten percent of the aggregate distributions  to  each general hospital made otherwise pursuant to this section and section twenty-eight hundred seven-w of this  article  shall be  reserved  and  set  aside  and  distributed  in  accordance with the following:  (a) Thirteen million nine hundred  thirty  thousand  dollars  of  such reserved  funds shall be distributed to major public hospitals and shall be  allocated  proportionally,  based  on   each   facility's   relative uncompensated  care need as determined in accordance with the provisions of paragraph (c) of this subdivision; and  (b) Seventy million seven hundred seventy  thousand  dollars  of  such reserved  funds  shall  be  distributed  to general hospitals other than major public general hospitals and shall  be  allocated  proportionally, based  on each facility's relative uncompensated care need as determined in accordance with the provisions of paragraph (c) of this  subdivision; and  (c)  For  the  purposes of distributions in accordance with paragraphs (a) and (b) of this subdivision, each facility's relative  uncompensated care need amount shall be determined in accordance with the following:  (i)  inpatient  units  of services for all uninsured patients from the calendar year two years prior to the distribution  year,  but  excluding referred  ambulatory  units  of  services,  shall  be  multiplied by the applicable Medicaid inpatient rates in effect for such prior  year,  but not  including  prospective rate adjustments and rate add-ons, provided, however, that for distributions on and after January first, two thousand ten, the uncompensated amount for inpatient services shall  utilize  the inpatient rates in effect as of July first of the prior year;  (ii)  outpatient  units of service for all uninsured patients from the calendar year two  years  prior  to  the  distribution  year,  including emergency  department  services  and  ambulatory  surgery  services, but excluding referred  ambulatory  services  units  of  service,  shall  be multiplied  by  Medicaid  outpatient  rates  that  reflect the exclusive utilization  of  the  ambulatory  patient  groups   (APG)   rate-setting methodology   as  set  forth  in  regulations  promulgated  pursuant  to subdivision two-a of section twenty-eight hundred seven of this article, as in effect for the distribution year, provided further, however,  that for  those services for which APG rates are not available the applicable Medicaid outpatient rate shall be the rate in effect  for  the  calendar year two years prior to the distribution year;  (iii) the uncompensated care need for each facility for periods on and after January first, two thousand ten shall be reduced by the sum of all payment amounts collected from such patients; and  (iv)  the  total  uncompensated care need for each facility subject to this subdivision shall then be adjusted by application  of  the  nominal need scale set forth in subdivision five of this section.  (d)(i)  For  annual periods commencing on and after January first, two thousand nine, no general hospital may  receive  disproportionate  share payment  distributions  made  in  accordance  with this section, section twenty-eight hundred seven-w of this article or made in accordance  with other  provisions  of law, that exceed, in aggregate, the costs incurred by such general hospital during such period in furnishing inpatient  and outpatient  hospital  services  to  Medicaid  eligible  patients  or  to patients who have no health insurance or other  source  of  third  party coverage,  net  of  all  monies received from non-disproportionate share related Medicaid payments and  from  payments  made  by  such  uninsured patients.  For purposes of this paragraph, non-Medicaid payments made to a general hospital by the state or by a unit of local government  within the  state  for  services  provided  to  indigent  patients shall not be considered to be a source of third party payment.  (ii) Reductions pursuant to  this  paragraph  shall  be  made  in  the following sequence:  (A)  payments  in  accordance  with  subdivision fourteen-f of section twenty-eight hundred seven-c of this article;  (B) payments made to eligible hospitals pursuant to this  section  and section twenty-eight hundred seven-w of this article.  (iii)  Notwithstanding  any  contrary  provision  of  this  section or section twenty-eight hundred seven-w of this article,  in  the  event  a payment  made  pursuant  to this section or section twenty-seven hundred seven-w  of  this  article  exceeds  a  hospital's  applicable  facility specific  disproportionate share limit, then fifty percent of the amount in excess of such limit shall be paid to such facility as a  grant  from state  funds  available for distribution in accordance with this section and section twenty-eight hundred  seven-w  of  this  article,  provided, however, that if payments made to an eligible rural hospital pursuant to this  subdivision  or  section  twenty-eight  hundred  seven-w  of  this article, result in payments in excess  of  such  disproportionate  share limits,  then  up to one hundred forty thousand dollars of such payments shall be made at one hundred percent of the amount  in  excess  of  such limits for each eligible rural hospital.  (e)   By   no  later  than  December  first,  two  thousand  ten,  the commissioner  shall  issue  a  report  evaluating  the  impact  of   the distributions  made pursuant to this subdivision with regard to units of service to uninsured patients provided by each facility, and with regard to the extent of services provided by each facility to patients eligible for financial aid in  accordance  with  each  facility's  financial  aid policies  and  procedures  as  mandated  by  subdivision  nine-a of this section. Such report shall also include the use of data on  services  to the  uninsured  to  model the impact of the distribution methodology set forth in this subdivision against all  funding  authorized  pursuant  to this section and section twenty-eight hundred seven-w of this article.  (f) The commissioner shall conduct outreach and educational activities to inform hospitals on matters relating to data collection and reporting requirements  related to services provided to the uninsured and patients eligible for financial aid, including definitions  to  be  utilized  for identifying  uninsured  units  of  service  and proper identification of out-of-pocket collections from uninsured patients.    5-b. Notwithstanding  any  inconsistent  provision  of  this  section, section  twenty-eight  hundred  seven-w  of  this  article  or any other contrary provision of law and subject to  the  availability  of  federal financial  participation,  for  periods  on  and  after  May  first, two thousand  nine, funds as hereinafter described shall be reserved and set aside and distributed in accordance with the following:  (a) For the period May  first,  two  thousand  nine  through  December thirty-first, two thousand nine payments shall be made as follows:  (i)  Ninety  percent  of  funds  available  for  the two thousand nine calendar year pursuant to paragraph (a-1) of subdivision  four  of  this section  shall  be  reserved  and  set aside and distributed as Medicaid disproportionate share (DSH) payments to the same hospitals and  in  the same  proportional  amounts as received pursuant to such paragraph (a-1) in two thousand eight;  (ii) Three hundred seven  million  dollars  shall  be  distributed  as Medicaid  DSH  payments  to  facilities  designated by the department as teaching hospitals as of December thirty-first, two  thousand  eight  in accordance  with  a  schedule of payments to be set forth in regulations promulgated by  the  commissioner  to  compensate  such  facilities  for Medicaid  and  self-pay  losses reported in each facility's two thousand seven annual cost report;  (iii) Sixteen million dollars shall be proportionally  distributed  as Medicaid  DSH  payments  to  non-teaching  hospitals  based  upon  their proportion  of  uninsured  losses  as  defined  in  paragraph   (c)   of subdivision  five-a  of  this section to such losses of all non-teaching hospitals on a statewide basis;  (iv) Twenty-five million dollars shall be distributed as Medicaid  DSH payments  to  non-major  public  hospitals having Medicaid discharges of forty percent or greater as established by the  commissioner  from  data reported  in  each  hospital's two thousand seven annual cost report, in accordance with a schedule to be set forth in regulations promulgated by the commissioner, to compensate such facilities for  projected  Medicaid net   losses,   as   determined   by  the  commissioner,  stemming  from modifications to Medicaid payments made pursuant to  a  chapter  of  the laws of two thousand nine.  (b)  For  annual  periods  beginning  January  first, two thousand ten payments shall be made as follows:  (i) Two hundred sixty-nine million five hundred thousand dollars shall be distributed as Medicaid DSH payments  to  non-major  public  teaching hospitals,  and  such distributions shall be made on a regional basis to cover,  within  amounts  available  for  each  region,   each   eligible facility's  proportional  regional  share of unmet need for two thousand seven, provided, however, that such regions and regional allocations and the  definition  of  unmet  need  shall  be  set  forth  in  regulations promulgated by the commissioner;  (ii)  Twenty-five million dollars shall be distributed as Medicaid DSH payments  to  hospitals  eligible  for   payments   made   pursuant   to subparagraph  (iv)  of paragraph (a) of this subdivision based upon each facility's proportion of uninsured losses, as defined in  paragraph  (c) of  subdivision five-a of this section, to such losses for all hospitals eligible for such payments;  (iii) Sixteen million dollars shall be distributed in accordance  with the   provisions   of  subparagraph  (iii)  of  paragraph  (a)  of  this subdivision;  (iv) Twenty-five million dollars shall be  distributed  in  accordance with  the  provisions  of  subparagraph  (iv)  of  paragraph (a) of this subdivision;    5-c. (a) Notwithstanding any contrary provision of law and subject  to the availability of federal financial participation, for the period July first, two thousand ten through December thirty-first, two thousand ten, distributions  pursuant to this section and section twenty-eight hundred seven-w  of  this  article,  shall  reflect  an  aggregate  reduction of sixty-nine  million  four  hundred  thousand  dollars,  based   on   the proportion  of  each  hospital's  indigent care allocations to the total allocations  of  all  hospitals'  indigent  care  allocations  prior  to application  of  this reduction, provided, however, that such reductions shall not  be  applied  to  distributions  to  major  public  hospitals, including   major   public   hospitals   operated   by   public  benefit corporations, and also  shall  not  be  applied  to  distributions  made pursuant  to  subparagraph  (ii),  (iii)  or  (iv)  of  paragraph (b) of subdivision five-b of this section.  (b) Notwithstanding any contrary provision of law and subject  to  the availability  of federal financial participation, for the period January first, two thousand eleven through December thirty-first,  two  thousand eleven and each calendar year thereafter, distributions pursuant to this section  and  section twenty-eight hundred seven-w of this article shall reflect an aggregate reduction  of  seventy-three  million  two  hundred thousand  dollars,  based  on the proportion of each hospital's indigent care allocation to the total allocations of all hospitals' indigent care allocations prior to application of this reduction,  provided,  however, that  such  reductions  shall  not  be applied to distributions to major public hospitals, including major public hospitals  operated  by  public benefit  corporations,  and  shall  also not be applied to distributions made pursuant to subparagraph (ii), (iii) or (iv) of  paragraph  (b)  of subdivision five-b of this section.   * 5-d. (a) Notwithstanding any inconsistent provision of this section, section  twenty-eight  hundred  seven-w  of  this  article  or any other contrary provision of law, and subject to the  availability  of  federal financial  participation,  for  periods  on and after January first, two thousand twenty, through March thirty-first, two thousand  twenty-three, all  funds  available  for distribution pursuant to this section, except for funds distributed pursuant to subparagraph (v) of paragraph  (b)  of subdivision  five-b  of  this  section,  and  all  funds  available  for distribution pursuant to section twenty-eight hundred  seven-w  of  this article,  shall  be reserved and set aside and distributed in accordance with the provisions of this subdivision.  (b) The commissioner shall promulgate regulations, and may  promulgate emergency  regulations,  establishing methodologies for the distribution of funds as described in paragraph (a)  of  this  subdivision  and  such regulations shall include, but not be limited to, the following:  (i)  Such  regulations  shall  establish methodologies for determining each  facility's  relative  uncompensated  care  need  amount  based  on uninsured  inpatient  and  outpatient  units  of  service  from the cost reporting year two years prior to the distribution year,  multiplied  by the   applicable   medicaid   rates  in  effect  January  first  of  the distribution year, as summed and adjusted by a statewide cost adjustment factor and reduced by the sum of all payment amounts collected from such uninsured patients, and as further adjusted by application of a  nominal need  computation  that shall take into account each facility's medicaid inpatient share.  (ii) Annual distributions pursuant to such  regulations  for  the  two thousand  twenty through two thousand twenty-two calendar years shall be in accord with the following:  (A) one hundred thirty-nine  million  four  hundred  thousand  dollars shall be distributed as Medicaid Disproportionate Share Hospital ("DSH") payments to major public general hospitals; and  (B)  nine  hundred sixty-nine million nine hundred thousand dollars as Medicaid DSH payments to eligible general hospitals,  other  than  major public general hospitals.   For  the  calendar  years  two  thousand  twenty  through two thousand twenty-two, the total distributions to eligible general hospitals, other than major public general hospitals, shall be subject  to  an  aggregate reduction  of  one hundred fifty million dollars annually, provided that eligible general hospitals, other than major public  general  hospitals, that qualify as enhanced safety net hospitals under section two thousand eight  hundred  seven-c  of  this  article  shall not be subject to such reduction.   Such reduction shall be determined by a methodology to be  established by  the  commissioner.  Such methodology may take into account the payor mix of each non-public general hospital,  including  the  percentage  of inpatient days paid by Medicaid.  (iii)  For  calendar  years  two  thousand twenty through two thousand twenty-two, sixty-four million six hundred  thousand  dollars  shall  be distributed  to  eligible  general  hospitals,  other  than major public general hospitals, that experience a reduction  in  indigent  care  pool payments  pursuant  to  this  subdivision,  and that qualify as enhanced safety net hospitals under section two thousand eight hundred seven-c of this article as of April first, two thousand twenty.  Such  distribution shall   be  established  pursuant  to  regulations  promulgated  by  the commissioner and shall be proportional to the reduction  experienced  by the facility.  (iv) Such regulations shall reserve one percent of the funds available for  distribution  in the two thousand fourteen and two thousand fifteen calendar years, and for calendar  years  thereafter,  pursuant  to  this subdivision,  subdivision  fourteen-f  of  section  twenty-eight hundred seven-c of this article, and sections two hundred eleven and two hundred twelve of chapter four hundred seventy-four  of  the  laws  of  nineteen hundred  ninety-six,  in  a  "financial  assistance compliance pool" and shall establish methodologies for the distribution of such pool funds to facilities based on their level of  compliance,  as  determined  by  the commissioner, with the provisions of subdivision nine-a of this section.  (c)  The  commissioner  shall  annually report to the governor and the legislature  on  the  distribution  of  funds  under  this   subdivision including, but not limited to:  (i) the impact on safety net providers, including community providers, rural general hospitals and major public general hospitals;  (ii)  the  provision  of  indigent care by units of services and funds distributed by general hospitals; and  (iii) the extent to which access to care has been enhanced.   * NB Effective until March 31, 2023   * 5-d. (a) Notwithstanding any inconsistent provision of this section, section twenty-eight hundred  seven-w  of  this  article  or  any  other contrary  provision  of  law, and subject to the availability of federal financial participation, for periods on and  after  January  first,  two thousand  thirteen, through March thirty-first, two thousand twenty, all funds available for distribution pursuant to this  section,  except  for funds  distributed  pursuant  to  subparagraph  (v)  of paragraph (b) of subdivision  five-b  of  this  section,  and  all  funds  available  for distribution  pursuant  to  section twenty-eight hundred seven-w of this article, shall be reserved and set aside and distributed  in  accordance with the provisions of this subdivision.  (b)  The commissioner shall promulgate regulations, and may promulgate emergency regulations, establishing methodologies for  the  distribution of  funds  as  described  in  paragraph (a) of this subdivision and such regulations shall include, but not be limited to, the following:  (i)  Such  regulations  shall  establish methodologies for determining each  facility's  relative  uncompensated  care  need  amount  based  on uninsured  inpatient  and  outpatient  units  of  service  from the cost reporting year two years prior to the distribution year,  multiplied  by the   applicable   medicaid   rates  in  effect  January  first  of  the distribution year, as summed and adjusted by a statewide cost adjustment factor and reduced by the sum of all payment amounts collected from such uninsured patients, and as further adjusted by application of a  nominal need  computation  that shall take into account each facility's medicaid inpatient share.  (ii) Annual distributions pursuant to such  regulations  for  the  two thousand thirteen through two thousand twenty calendar years shall be in accord with the following:  (A)  one  hundred  thirty-nine  million  four hundred thousand dollars shall be distributed as Medicaid Disproportionate Share Hospital ("DSH") payments to major public general hospitals; and  (B) nine hundred ninety-four million nine hundred thousand dollars  as Medicaid  DSH  payments  to eligible general hospitals, other than major public general hospitals.  (iii)(A) Such regulations shall establish  transition  adjustments  to the  distributions  made pursuant to clauses (A) and (B) of subparagraph (ii) of this paragraph such that no facility experiences a reduction  in indigent care pool payments pursuant to this subdivision that is greater than the percentages, as specified in clause (C) of this subparagraph as compared  to  the  average distribution that each such facility received for the three calendar years prior to two thousand thirteen pursuant  to this section and section twenty-eight hundred seven-w of this article.  (B)  Such  regulations  shall  also establish adjustments limiting the increases in indigent  care  pool  payments  experienced  by  facilities pursuant to this subdivision by an amount that will be, as determined by the  commissioner  and  in conjunction with such other funding as may be available for this purpose, sufficient to ensure full  funding  for  the transition   adjustment  payments  authorized  by  clause  (A)  of  this subparagraph.  (C) No facility shall experience a reduction  in  indigent  care  pool payments  pursuant  to  this  subdivision  that:  for  the calendar year beginning January first, two thousand thirteen, is greater than two  and one-half  percent;  for  the  calendar year beginning January first, two thousand fourteen, is greater than five percent; and, for  the  calendar year  beginning  on January first, two thousand fifteen; is greater than seven and one-half percent, and  for  the  calendar  year  beginning  on January  first,  two  thousand sixteen, is greater than ten percent; and for  the  calendar  year  beginning  on  January  first,  two   thousand seventeen,  is  greater  than  twelve  and one-half percent; and for the calendar year beginning on January  first,  two  thousand  eighteen,  is greater  than  fifteen  percent;  and for the calendar year beginning on January first, two thousand nineteen,  is  greater  than  seventeen  and one-half  percent; and for the calendar year beginning on January first, two thousand twenty, is greater than twenty percent.  (iv) Such regulations shall reserve one percent of the funds available for distribution in the two thousand fourteen and two  thousand  fifteen calendar  years,  and  for  calendar  years thereafter, pursuant to this subdivision, subdivision  fourteen-f  of  section  twenty-eight  hundred seven-c of this article, and sections two hundred eleven and two hundred  twelve  of  chapter  four  hundred  seventy-four of the laws of nineteen hundred ninety-six, in a  "financial  assistance  compliance  pool"  and shall establish methodologies for the distribution of such pool funds to facilities  based  on  their  level  of compliance, as determined by the commissioner, with the provisions of subdivision nine-a of this section.  (c) The commissioner shall annually report to  the  governor  and  the legislature   on  the  distribution  of  funds  under  this  subdivision including, but not limited to:  (i) the impact on safety net providers, including community providers, rural general hospitals and major public general hospitals;  (ii) the provision of indigent care by units  of  services  and  funds distributed by general hospitals; and  (iii) the extent to which access to care has been enhanced.   * NB Effective March 31, 2023   6.  Funds  reserved  for high need adjustments shall be distributed to general  hospitals,  excluding  major  public  general  hospitals,  with nominal  need  in  excess  of  four  percent  as  follows:  each general hospital's  share  of  the  reserved  amount  shall  be  based  on  such hospital's  aggregate  share of nominal need above four percent compared to the total aggregate nominal need above four percent of  all  eligible hospitals.   7.  (a)  Hospital  specific transition adjustment. Notwithstanding any inconsistent  provision  of  this  section,  distributions  to   general hospitals determined in accordance with subdivision four of this section shall be adjusted as follows:  (i)  For  general hospitals which qualified for distributions pursuant to paragraph (c) of subdivision nineteen of section twenty-eight hundred seven-c of this article as of December  thirty-first,  nineteen  hundred ninety-five:  (A)  for  the  period  January  first,  nineteen  hundred ninety-seven through December thirty-first, nineteen hundred ninety-seven, each  such general  hospital  shall receive as an allocation one hundred percent of the  projected  distribution,  as  of  June  first,   nineteen   hundred ninety-seven,   to   such  general  hospital  pursuant  to  subdivisions fourteen-c and seventeen and paragraph (c) of  subdivision  nineteen  of section  twenty-eight  hundred  seven-c  of  this  article  for nineteen hundred ninety-six; and  (B) for  the  period  January  first,  nineteen  hundred  ninety-eight through  December thirty-first, nineteen hundred ninety-eight, each such general hospital shall receive as an allocation seventy-five percent  of the amount determined in accordance with clause (A) of this subparagraph and  twenty-five  percent  of  the  amount determined in accordance with subdivision four of this section; and  (C) for the period January first, nineteen hundred ninety-nine through December thirty-first, nineteen hundred ninety-nine, each  such  general hospital  shall  receive  as  an  allocation fifty percent of the amount determined in accordance with clause (A) of this subparagraph and  fifty percent  of the amount determined in accordance with subdivision four of this section; and  (D) for the  period  January  first,  two  thousand  through  December thirty-first,  two thousand, each such general hospital shall receive as an allocation twenty-five percent of the amount determined in accordance with clause (A) of this subparagraph and  seventy-five  percent  of  the amount  determined  in  accordance with subdivision four of this section provided, however, that for any general hospital whose  distribution  is greater  when determined solely in accordance with subdivisions four and six of this section than when determined according to this clause,  such  general  hospital's  distribution shall not be adjusted pursuant to this clause; and  (E)  for  periods  on  and after January first, two thousand one, each such general hospital shall receive as an allocation one hundred percent of the amount determined in accordance with  subdivision  four  of  this section.  (ii)  For  all other general hospitals, excluding major public general hospitals, general hospitals qualifying for an  adjustment  pursuant  to subparagraph  (i)  of  this paragraph, general hospitals which qualified for  an  adjustment  pursuant  to  subdivision  fourteen-d  of   section twenty-eight hundred seven-c of this article and rural general hospitals that  met  the  qualifications  as  a rural general hospital pursuant to paragraph (f)  of  subdivision  four  of  section  twenty-eight  hundred seven-c of this article in nineteen hundred ninety-six:  (A)  for  the  period  January  first,  nineteen  hundred ninety-seven through December thirty-first, nineteen hundred ninety-seven, each  such general  hospital  shall  receive  as an allocation fifty percent of the projected distribution, as of June first, nineteen hundred ninety-seven, to such general hospital pursuant to subdivision  seventeen  of  section twenty-eight  hundred  seven-c  of  this  article  for  nineteen hundred ninety-six and fifty percent of the amount determined in accordance with subdivision four of this section; and  (B) for  the  period  January  first,  nineteen  hundred  ninety-eight through  December thirty-first, nineteen hundred ninety-eight, each such general hospital shall receive as an allocation twenty-five  percent  of the   projected   distribution,  as  of  June  first,  nineteen  hundred ninety-seven, to such general hospital pursuant to subdivision seventeen of section twenty-eight hundred seven-c of  this  article  for  nineteen hundred  ninety-six and seventy-five percent of the amount determined in accordance with subdivision four of this section.  (b) Hospital category  adjustment.  Notwithstanding  any  inconsistent provision  of  this  section,  distributions  to  each general hospital, excluding  major  public  general  hospitals,   for   nineteen   hundred ninety-seven  determined  in  accordance  with  subdivision four of this section and paragraph (a) of  this  subdivision  within  the  categories specified  in  subparagraph  (i)  of this paragraph shall be adjusted in accordance with subparagraph (ii) of this paragraph.  (i)(A)  General  hospitals  that  qualified   for   distributions   in accordance  with  subdivision fourteen-d of section twenty-eight hundred seven-c of this article for nineteen hundred ninety-six.  (B) Rural general hospitals that met the  qualifications  as  a  rural general  hospital  pursuant  to  paragraph  (f)  of  subdivision four of section twenty-eight  hundred  seven-c  of  this  article  for  nineteen hundred ninety-six.  (C)  All  other  general  hospitals,  excluding general hospitals that qualified for distributions pursuant to  paragraph  (c)  of  subdivision nineteen of section twenty-eight hundred seven-c of this article.  (ii)   For  each  category  specified  in  subparagraph  (i)  of  this paragraph, fifty percent of the amount by which the allocation  pursuant to   subdivision  four  of  this  section  and  paragraph  (a)  of  this subdivision to a general  hospital  within  such  category  exceeds  the projected distribution, as of June first, nineteen hundred ninety-seven, pursuant  to  subdivision  seventeen  and,  if  applicable,  subdivision fourteen-d of section twenty-eight hundred seven-c of this  article  for nineteen  hundred  ninety-six to such general hospital shall be reserved by the commissioner for allocation  to  general  hospitals  within  such category  that would experience a loss based on such comparison based on each such general hospital's proportionate share of the aggregate losses  for all general hospitals within such category; provided  however,  that the  amount  reserved  within  a category shall not exceed the aggregate amount of losses within such category.   8.  Notwithstanding  any inconsistent provision of this section, up to five percent of the  amount  allocated  for  each  of  the  periods  for distributions  pursuant  to  this  section  may  be  transferred  by the commissioner,  to  the  extent  of  funds  appropriated  therefor,   and allocated  for distributions pursuant to the child health insurance plan established pursuant to title  one-A  of  article  twenty-five  of  this chapter.   9.  In order for a general hospital to participate in the distribution of funds from the pool, the  general  hospital  must  implement  minimum collection policies and procedures approved by the commissioner.   9-a.  (a)  As  a  condition  for  participation  in pool distributions authorized pursuant to this section  and  section  twenty-eight  hundred seven-w  of  this  article  for  periods on and after January first, two thousand nine, general hospitals shall, effective  for  periods  on  and after  January  first,  two  thousand  seven,  establish  financial  aid policies and procedures, in  accordance  with  the  provisions  of  this subdivision,  for  reducing  charges  otherwise applicable to low-income individuals without health insurance, or who have exhausted their health insurance benefits, and who can demonstrate an  inability  to  pay  full charges,  and  also,  at  the  hospital's  discretion,  for  reducing or discounting the collection of co-pays and deductible payments from those individuals who can demonstrate an inability to pay such amounts.  (b) Such reductions from charges for uninsured patients  with  incomes below  at least three hundred percent of the federal poverty level shall result in a charge to such individuals that does not exceed the  greater of  the  amount  that  would have been paid for the same services by the "highest  volume  payor"  for  such  general  hospital  as  defined   in subparagraph (v) of this paragraph, or for services provided pursuant to title  XVIII  of  the  federal  social  security  act (medicare), or for services provided pursuant to title XIX of the federal  social  security act (medicaid), and provided further that such amounts shall be adjusted according to income level as follows:  (i) For patients with incomes at or below at least one hundred percent of  the federal poverty level, the hospital shall collect no more than a nominal payment amount, consistent with guidelines  established  by  the commissioner;  (ii)  For  patients  with  incomes  between  at  least one hundred one percent and one hundred fifty percent of the federal poverty level,  the hospital  shall  collect  no  more  than  the  amount  identified  after application of a proportional sliding fee schedule under which  patients with  lower  incomes  shall  pay  the lowest amount. Such schedule shall provide that the amount the  hospital  may  collect  for  such  patients increases  from the nominal amount described in subparagraph (i) of this paragraph in equal increments as the income of the patient increases, up to a maximum of twenty percent of the greater of the amount  that  would have  been  paid for the same services by the "highest volume payor" for such general hospital, as defined in subparagraph (v) of this paragraph, or for services provided pursuant to title XVIII of the  federal  social security  act  (medicare) or for services provided pursuant to title XIX of the federal social security act (medicaid);  (iii) For patients with incomes between at least one hundred fifty-one percent and two hundred fifty percent of the federal poverty level,  the hospital  shall  collect  no  more  than  the  amount  identified  after application of a proportional sliding fee schedule under which  patients with  lower  income  shall  pay  the lowest amounts. Such schedule shall  provide that the amount the  hospital  may  collect  for  such  patients increases  from the twenty percent figure described in subparagraph (ii) of this paragraph in equal increments  as  the  income  of  the  patient increases,  up to a maximum of the greater of the amount that would have been paid for the same services by the "highest volume payor"  for  such general  hospital,  as defined in subparagraph (v) of this paragraph, or for services provided pursuant to title  XVIII  of  the  federal  social security  act  (medicare) or for services provided pursuant to title XIX of the federal social security act (medicaid); and  (iv) For patients with incomes between at least two hundred  fifty-one percent  and  three  hundred  percent  of the federal poverty level, the hospital shall collect no more than the greater of the amount that would have been paid for the same services by the "highest volume  payor"  for such  general hospital as defined in subparagraph (v) of this paragraph, or for services provided pursuant to title XVIII of the  federal  social security  act (medicare), or for services provided pursuant to title XIX of the federal social security act (medicaid).  (v) For the purposes of this paragraph, "highest volume  payor"  shall mean  the  insurer,  corporation  or organization licensed, organized or certified pursuant to article thirty-two, forty-two  or  forty-three  of the  insurance  law  or  article  forty-four  of  this chapter, or other third-party payor, which has a contract or agreement to pay  claims  for services  provided  by  the  general  hospital  and incurred the highest volume of claims in the previous calendar year.  (vi) A hospital may implement policies and procedures to  permit,  but not  require, consideration on a case-by-case basis of exceptions to the requirements described in subparagraphs (i) and (ii) of  this  paragraph based upon the existence of significant assets owned by the patient that should  be  taken  into  account  in determining the appropriate payment amount for that patient's care, provided, however,  that  such  proposed policies  and  procedures  shall  be  subject  to  the  prior review and approval of the commissioner and, if approved, shall be included in  the hospital's  financial  assistance  policy  established  pursuant to this section, and provided further that, if such  approval  is  granted,  the maximum amount that may be collected shall not exceed the greater of the amount  that  would have been paid for the same services by the "highest volume payor" for such general hospital as defined in  subparagraph  (v) of  this  paragraph, or for services provided pursuant to title XVIII of the federal social security act (medicare),  or  for  services  provided pursuant  to title XIX of the federal social security act (medicaid). In the event  that  a  general  hospital  reviews  a  patient's  assets  in determining  payment  adjustments such policies and procedures shall not consider as assets a patient's  primary  residence,  assets  held  in  a tax-deferred  or  comparable retirement savings account, college savings accounts, or cars used  regularly  by  a  patient  or  immediate  family members.  (vii)  Nothing  in  this  paragraph  shall  be  construed  to  limit a hospital's  ability  to  establish  patient  eligibility   for   payment discounts  at income levels higher than those specified herein and/or to provide greater payment  discounts  for  eligible  patients  than  those required by this paragraph.  (c)  Such  policies  and procedures shall be clear, understandable, in writing and publicly available in summary form and each general hospital participating in the pool shall ensure that every patient is made  aware of  the  existence of such policies and procedures and is provided, in a timely manner, with a summary  of  such  policies  and  procedures  upon request.  Any  summary provided to patients shall, at a minimum, include specific information as to income levels used to  determine  eligibility  for  assistance,  a  description  of  the  primary  service  area of the hospital and the means of applying for assistance. For general hospitals with  twenty-four  hour  emergency  departments,   such   policies   and procedures  shall require the notification of patients during the intake and  registration  process,   through   the   conspicuous   posting   of language-appropriate   information   in   the   general   hospital,  and information on bills and statements sent to patients, that financial aid may be available  to  qualified  patients  and  how  to  obtain  further information.  For specialty hospitals without twenty-four hour emergency departments,  such  notification  shall  take  place   through   written materials  provided  to  patients  during  the  intake  and registration process  prior  to  the  provision  of  any  health  care  services   or procedures,  and  through  information  on  bills and statements sent to patients, that financial aid may be available to qualified patients  and how to obtain further information. Application materials shall include a notice  to  patients  that  upon  submission of a completed application, including any information  or  documentation  needed  to  determine  the patient's  eligibility  pursuant  to the hospital's financial assistance policy, the patient may disregard  any  bills  until  the  hospital  has rendered   a  decision  on  the  application  in  accordance  with  this paragraph.  (d) Such  policies  and  procedures  shall  include  clear,  objective criteria  for  determining  a patient's ability to pay and for providing such adjustments to payment requirements as are necessary.  In  addition to  adjustment mechanisms such as sliding fee schedules and discounts to fixed standards, such policies and procedures shall also provide for the use of installment plans for the  payment  of  outstanding  balances  by patients   pursuant  to  the  provisions  of  the  hospital's  financial assistance policy. The monthly payment  under  such  a  plan  shall  not exceed ten percent of the gross monthly income of the patient, provided, however, that if patient assets are considered under such a policy, then patient  assets  which  are not excluded assets pursuant to subparagraph (vi) of paragraph (b) of this subdivision may be considered in  addition to  the  limit  on monthly payments. The rate of interest charged to the patient on the unpaid balance, if any, shall not exceed the rate  for  a ninety-day  security issued by the United States Department of Treasury, plus .5 percent and no plan shall  include  an  accelerator  or  similar clause  under which a higher rate of interest is triggered upon a missed payment. If such policies and procedures  include  a  requirement  of  a deposit  prior  to  non-emergent, medically-necessary care, such deposit must be included as  part  of  any  financial  aid  consideration.  Such policies  and  procedures  shall be applied consistently to all eligible patients.  (e) Such policies and procedures shall permit patients  to  apply  for assistance  within at least ninety days of the date of discharge or date of service and provide at least twenty days for  patients  to  submit  a completed  application.  Such  policies  and procedures may require that patients  seeking  payment  adjustments  provide  appropriate  financial information and documentation in support of their application, provided, however, that such application process shall not be unduly burdensome or complex.  General  hospitals  shall,  upon  request,  assist patients in understanding the hospital's policies and procedures and in applying for payment adjustments. Application forms shall be printed in the  "primary languages"  of patients served by the general hospital. For the purposes of this paragraph, "primary languages" shall include any  language  that is  either  (i)  used  to  communicate,  during at least five percent of patient visits in a year, by patients who cannot speak, read,  write  or understand  the  English  language at the level of proficiency necessary  for effective communication with health care providers, or  (ii)  spoken by  non-English speaking individuals comprising more than one percent of the primary  hospital  service  area  population,  as  calculated  using demographic  information  available from the United States Bureau of the Census, supplemented by data from school  systems.  Decisions  regarding such  applications  shall  be  made  within  thirty days of receipt of a completed application. Such policies and procedures shall  require  that the  hospital  issue  any denial/approval of such application in writing with information on how to appeal  the  denial  and  shall  require  the hospital  to  establish  an appeals process under which it will evaluate the denial of an application.  Nothing  in  this  subdivision  shall  be interpreted  as  prohibiting  a hospital from making the availability of financial assistance contingent upon  the  patient  first  applying  for coverage  under  title  XIX  of  the  social  security act (medicaid) or another insurance program if, in  the  judgment  of  the  hospital,  the patient  may  be eligible for medicaid or another insurance program, and upon the patient's cooperation in  following  the  hospital's  financial assistance   application   requirements,   including  the  provision  of information needed to make a determination on the patient's  application in accordance with the hospital's financial assistance policy.  (f)  Such  policies  and  procedures  shall provide that patients with incomes below three hundred percent of the  federal  poverty  level  are deemed  presumptively eligible for payment adjustments and shall conform to the requirements set forth in  paragraph  (b)  of  this  subdivision, provided, however, that nothing in this subdivision shall be interpreted as precluding hospitals from extending such payment adjustments to other patients, either generally or on a case-by-case basis. Such policies and procedures  shall provide financial aid for emergency hospital services, including emergency transfers pursuant to the federal emergency  medical treatment  and  active labor act (42 USC 1395dd), to patients who reside in New York state and for  medically  necessary  hospital  services  for patients who reside in the hospital's primary service area as determined according  to  criteria  established  by the commissioner. In developing such criteria, the commissioner shall consult  with  representatives  of the  hospital  industry, health care consumer advocates and local public health officials. Such criteria shall be made available to the public no less than thirty days prior to the date of implementation and shall,  at a minimum:  (i)  prohibit  a  hospital  from  developing  or  altering its primary service area  in  a  manner  designed  to  avoid  medically  underserved communities or communities with high percentages of uninsured residents;  (ii)  ensure that every geographic area of the state is included in at least one general hospital's  primary  service  area  so  that  eligible patients may access care and financial assistance; and  (iii)  require the hospital to notify the commissioner upon making any change to its primary service area, and to include a description of  its primary  service  area  in  the  hospital's annual implementation report filed pursuant to subdivision  three  of  section  twenty-eight  hundred three-l of this article.  (g)  Nothing  in  this  subdivision shall be interpreted as precluding hospitals from extending payment  adjustments  for  medically  necessary non-emergency  hospital  services  to patients outside of the hospital's primary service  area.  For  patients  determined  to  be  eligible  for financial aid under the terms of a hospital's financial aid policy, such policies  and procedures shall prohibit any limitations on financial aid for services based on the medical condition of the applicant, other than typical limitations or exclusions based  on  medical  necessity  or  the clinical or therapeutic benefit of a procedure or treatment.  (h)  Such  policies and procedures shall not permit the forced sale or foreclosure of a patient's primary residence  in  order  to  collect  an outstanding  medical bill and shall require the hospital to refrain from sending an  account  to  collection  if  the  patient  has  submitted  a completed   application   for  financial  aid,  including  any  required supporting documentation, while the hospital  determines  the  patient's eligibility for such aid. Such policies and procedures shall provide for written  notification,  which  shall  include  notification on a patient bill, to a patient not less than thirty days prior to  the  referral  of debts for collection and shall require that the collection agency obtain the  hospital's written consent prior to commencing a legal action. Such policies and procedures shall require all  general  hospital  staff  who interact   with   patients   or  have  responsibility  for  billing  and collections to be trained in such policies and procedures,  and  require the  implementation  of  a mechanism for the general hospital to measure its compliance with such policies  and  procedures.  Such  policies  and procedures  shall require that any collection agency under contract with a general hospital for the collection of  debts  follow  the  hospital's financial assistance policy, including providing information to patients on  how  to  apply  for  financial  assistance  where  appropriate. Such policies and procedures shall prohibit collections from a patient who is determined to be eligible for medical assistance pursuant to  title  XIX of  the  federal  social security act at the time services were rendered and for which services medicaid payment is available.  (i) Reports required to be submitted to the department by each general hospital as a condition  for  participation  in  the  pools,  and  which contain, in accordance with applicable regulations, a certification from an  independent  certified  public  accountant  or  independent licensed public accountant or an  attestation  from  a  senior  official  of  the hospital   that  the  hospital  is  in  compliance  with  conditions  of participation in the pools, shall also contain, for reporting periods on and after January first, two thousand seven:  (i) a report on hospital costs incurred  and  uncollected  amounts  in providing services to eligible patients without insurance, including the amount  of care provided for a nominal payment amount, during the period covered by the report;  (ii) hospital costs incurred and uncollected amounts  for  deductibles and   coinsurance   for   eligible  patients  with  insurance  or  other third-party payor coverage;  (iii) the number of patients, organized  according  to  United  States postal  service  zip code, who applied for financial assistance pursuant to the hospital's financial assistance policy, and the number, organized according to United States postal service zip code,  whose  applications were approved and whose applications were denied;  (iv)  the  reimbursement  received  for  indigent  care  from the pool established pursuant to this section;  (v) the amount of funds that have been expended on charity  care  from charitable  bequests  made  or  trusts  established  for  the purpose of providing  financial  assistance  to  patients  who  are   eligible   in accordance with the terms of such bequests or trusts;  (vi)  for  hospitals located in social services districts in which the district allows hospitals to assist patients with such applications, the number of applications for eligibility under title  XIX  of  the  social security   act   (medicaid)  that  the  hospital  assisted  patients  in completing and the number denied and approved;  (vii) the hospital's financial losses resulting from services provided under medicaid; and  (viii) the number  of  liens  placed  on  the  primary  residences  of patients through the collection process used by a hospital.  (j)  Within ninety days of the effective date of this subdivision each hospital shall submit to  the  commissioner  a  written  report  on  its policies  and  procedures for financial assistance to patients which are used by the hospital on the effective date  of  this  subdivision.  Such report  shall  include  copies of its policies and procedures, including material which is distributed to patients,  and  a  description  of  the hospital's financial aid policies and procedures. Such description shall include the income levels of patients on which eligibility is based, the financial  aid  eligible  patients  receive and the means of calculating such aid, and the  service  area,  if  any,  used  by  the  hospital  to determine eligibility.  (k)  In  the event it is determined by the commissioner that the state will be unable to secure all necessary federal approvals to include,  as part  of  the  state's  approved  state plan under title nineteen of the federal social security act, a requirement, as set  forth  in  paragraph one  of  this  subdivision,  that  compliance with this subdivision is a condition of participation in pool distributions authorized pursuant  to this  section  and section twenty-eight hundred seven-w of this article, then such condition of participation shall be deemed null and void  and, notwithstanding  section  twelve of this chapter, failure to comply with the provisions of this subdivision by a hospital on and after  the  date of  such  determination  shall  make  such  hospital  liable for a civil penalty not to exceed ten thousand dollars for each such violation.  The imposition of such civil penalties shall be subject to the provisions of section twelve-a of this chapter.   10. In order for a general hospital to be eligible for distribution of funds  from  the  pool, such general hospital if it provides obstetrical care and services must be in compliance with the provisions of paragraph (e) of subdivision sixteen of section twenty-eight  hundred  seven-c  of this article.   11.  Minimum  hospital  procedures  to  determine  the availability of insurance or other third-party coverage for hospital services  shall  be specified by the commissioner.   12.  Each  general  hospital shall submit reports to the department at such time and in such form as the commissioner shall require of:  (a) hospital costs  incurred  and  uncollected  amounts  in  providing services to the uninsured during the period covered by the report; and  (b)  hospital  costs  incurred and uncollected amounts for deductibles and coinsurance for patients with insurance or other  third-party  payor coverage.  (c)   Such  reports  shall  comply  with  the  reporting  requirements established for receipt of bad debt and charity care  pool  payments  as provided in accordance with section twenty-eight hundred seven-c of this article  and  regulations  promulgated  thereunder  for periods prior to January first, nineteen hundred ninety-seven.   13. Distributions to general hospitals pursuant to  this  section  and the  adjustments  provided  in accordance with subdivision fourteen-f of section twenty-eight hundred seven-c of this article shall be considered disproportionate share  payments  for  inpatient  hospital  services  to general  hospitals  serving  a  disproportionate  number  of  low income patients with special needs for purposes of providing assurances to  the secretary  of  health  and  human  services as necessary to meet federal requirements for securing federal financial  participation  pursuant  to title XIX of the federal social security act.   14. Notwithstanding any inconsistent provision of law to the contrary, the  availability  or payment of funds to a general hospital pursuant to  this section shall not be admissible as a defense, offset  or  reduction in  any  action  or proceeding relating to any bill or claim for amounts due for hospital services provided.   15.   Revenue   from   distributions  pursuant  to  this  section  and adjustments pursuant to subdivision fourteen-f of  section  twenty-eight hundred  seven-c  of this article shall not be included in gross revenue received  for  purposes  of  the  assessments  pursuant  to  subdivision eighteen  of  section  twenty-eight  hundred  seven-c  of  this article, subject to the provisions of paragraph (e) of  subdivision  eighteen  of section  twenty-eight  hundred seven-c of this article, and shall not be included in gross revenue  received  for  purposes  of  the  assessments pursuant  to  section  twenty-eight  hundred  seven-d  of  this article, subject to the provisions of subdivision twelve of section  twenty-eight hundred seven-d of this article.   16. Supplemental indigent care distributions. From available resources established  pursuant  to  paragraph  (a-1)  of subdivision four of this section, each hospital shall receive  a  proportionate  share,  provided that no hospital shall receive less than the reduction amount calculated pursuant  to  paragraph (d) of subdivision three of section twenty-eight hundred  seven-m  of  this  article,  subject   to   hospital   specific disproportionate  share  payment  limits  calculated  in accordance with subdivision twenty-one of section twenty-eight hundred seven-c  of  this article.   17.  Indigent  care  reductions.  For each hospital receiving payments pursuant  to  paragraph  (i)  of  subdivision  thirty-five  of   section twenty-eight  hundred  seven-c  of  this article, the commissioner shall reduce the sum of any amounts paid pursuant to this section and pursuant to section twenty-eight hundred seven-w of  this  article,  as  computed based  on  projected  facility  specific disproportionate share hospital ceilings, by an amount equal to the lower  of  such  sum  or  each  such hospital's payments pursuant to paragraph (i) of subdivision thirty-five of  section  twenty-eight  hundred  seven-c  of  this article, provided, however, that any additional aggregate reductions enacted in  a  chapter of  the  laws  of  two  thousand  ten  to  the aggregate amounts payable pursuant to this section and pursuant to  section  twenty-eight  hundred seven-w  of  this article shall be applied subsequent to the adjustments otherwise provided for in this subdivision.