2023 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.
* (h)  "Underinsured"  shall  mean  an  individual  with out of pocket
medical costs accumulated in the past twelve months that amount to  more
than ten percent of such individual's gross annual income.
* NB Effective October 20, 2024
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-six,
all funds available for distribution pursuant to  this  section,  except
for funds distributed pursuant to 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-five 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.
For the calendar years two thousand twenty-three through two  thousand
twenty-five,  the  total  distributions  to  eligible general hospitals,
other than major public  general  hospitals,  shall  be  subject  to  an
aggregate  reduction  of  two  hundred  thirty-five million four hundred
thousand 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 as of April  first,  two  thousand  twenty,  shall  not  be
subject to such reduction.
Such reductions shall be determined by a methodology to be established
by  the commissioner. Such methodologies 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-five, 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.
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,
utilizing  only  a  uniform  financial  assistance  form  developed  and
provided by the department.
* NB Effective until October 20, 2024
* 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,
utilizing  only  a  uniform  financial  assistance  form  developed  and
provided   by   the  department.  All  general  hospitals  that  do  not
participate  in  the  indigent  care  pool  shall  also utilize only the
uniform financial assistance form and otherwise comply with  subdivision
nine-a  of  this section governing the provision of financial assistance
and hospital collection procedures.
* NB Effective October 20, 2024
* 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.
* NB Effective until October 20, 2024
* 9-a.  (a) 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 underinsured  individuals,  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.
Immigration status shall not be an eligibility criterion for the purpose
of determining financial assistance under this section.
(b) Such reductions from charges for patients with  incomes  below  at
least  four hundred percent of the federal poverty level shall result in
a charge to such individuals that does not exceed the amount that  would
have  been  paid for the same 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 below at least two hundred percent of
the federal poverty level, the hospital  shall  waive  all  charges.  No
nominal payment shall be collected;
(ii)  For  patients  with incomes between at least two hundred percent
and up to three hundred  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 in equal increments as the income of the patient increases, up
to  a maximum of ten percent of the amount that would have been paid for
the same services provided pursuant to title XIX of the  federal  social
security  act  (medicaid), or for underinsured patients, up to a maximum
of ten percent of the amount that would have been paid pursuant to  such
patient's insurance cost sharing;
(iii)  For  patients  with  incomes between at least three hundred one
percent and four hundred 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 ten percent figure described in subparagraph (ii) of
this paragraph  in  equal  increments  as  the  income  of  the  patient
increases,  up  to  a maximum of twenty percent of the amount that would
have been paid for the same services provided pursuant to title  XIX  of
the   federal  social  security  act  (medicaid),  or  for  underinsured
patients, up to a maximum of twenty percent of  the  amount  that  would
have  been  paid pursuant to such patient's insurance cost sharing; (iv)
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.  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 written notification of patients during the intake and
registration process, and during discharge of the patient,  and  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 during discharge of the patient, 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 financial assistance policy.
The monthly payment under such a plan shall not exceed five  percent  of
the gross monthly income of the patient. The rate of interest charged to
the  patient on the unpaid balance, if any, shall not exceed two 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 at any time during the collection process. 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 publicly subsidized insurance program if,  in  the
judgment  of  the  hospital, the patient may be eligible for medicaid or
another publicly subsidized insurance program, and  upon  the  patient's
cooperation   in   following   the   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,  provided,  however,  that  this
requirement  shall  not  apply  to  any patient that would otherwise not
qualify for coverage based on their immigration status.
(f) Such policies and procedures  shall  provide  that  patients  with
incomes  below  four  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  prohibit  the  denial  of
admission or denial  of  treatment  for  services  that  are  reasonably
anticipated  to be medically necessary because the patient has an unpaid
medical bill.  Such policies and procedures shall  prohibit  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 prohibit
the sale of medical debt accumulated pursuant to this section to a third
party, unless the third party explicitly purchases such medical debt  in
order  to  relieve the debt of the patient. 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  prohibit  a  hospital  from
commencing  a  legal  action  related to the recovery of medical debt or
unpaid bills against patients with incomes below four hundred percent of
the federal poverty level. In any legal action related to  the  recovery
of  medical  debt  or  unpaid  bills  by or on behalf of a hospital, the
complaint shall be accompanied by an affidavit by the  hospital's  chief
financial  officer  stating  that  based  upon the hospital's reasonable
effort to determine the patient's income,  the  patient  whom  they  are
taking  legal  action against does not have an income below four hundred
percent of the federal poverty level. 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  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 number of patients, including  their  age,  race,  ethnicity,
gender  and insurance status, who applied for financial assistance under
the hospital's financial assistance policy, and the number of  patients,
including their age, race, ethnicity, gender and insurance status, whose
applications were approved and denied;
(v)  the  reimbursement  received  for  indigent  care  from  the pool
established pursuant to this section;
(vi) 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;
(vii)  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; and
(viii)  the  hospital's  financial  losses  resulting  from   services
provided under medicaid.
(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)  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.
(l)  A  hospital  or  its  collection agent shall not commence a civil
action against a patient or delegate a collection  activity  to  a  debt

collector  for nonpayment for at least one hundred eighty days after the
first post-service  bill  is  issued  and  until  a  hospital  has  made
reasonable   efforts  to  determine  whether  a  patient  qualifies  for
financial assistance.
* NB Effective October 20, 2024
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.