A 1915: Requires health care plans and payors to have a minimum of twelve and one-half percent of their total expenditures on physical and mental health annually be for primary care services.

  
  STATE OF NEW YORK ________________________________________________________________________ 1915 2025-2026 Regular Sessions  IN ASSEMBLY January 14, 2025 ___________ Introduced by M. of A. PAULIN, WEPRIN, HEVESI, REYES, SIMONE, BICHOTTE HERMELYN, LUNSFORD -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law and the social services law, in relation to primary care investment The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. The insurance law is amended by adding a new section 3217-k 2 to read as follows: 3 § 3217-k. Primary care spending. (a) Definitions. As used in this 4 section, the following terms shall have the following meanings: 5 (1) "Overall healthcare spending" means the total cost of care for the 6 patient population of a payor or provider entity for a given calendar 7 year, where cost is calculated for such year as the sum of (A) all 8 claims-based spending paid to providers by public and private payors and 9 (B) all non-claim payments for such year, including, but not limited to, 10 incentive payments and care coordination payments. 11 (2) "Plan or payor" means every insurance entity providing managed 12 care products, individual comprehensive accident and health insurance or 13 group or blanket comprehensive accident and health insurance, as defined 14 in this chapter, corporation organized under article forty-three of this 15 chapter providing comprehensive health insurance, entity licensed under 16 article forty-four of this chapter providing comprehensive health insur- 17 ance, every other plan over which the department has jurisdiction, and 18 every third-party payor providing health coverage. 19 (3) "Primary care" means integrated, accessible healthcare, provided 20 by clinicians accountable for addressing most of a patient's healthcare 21 needs including (A) developing a sustained partnership with patients; 22 (B) practicing in the context of family and community; and (C) coordi- 23 nating patients' care, which for the purposes of this section shall only 24 include care coordination efforts undertaken by the clinicians rendering EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD04789-01-5 
 A. 1915 2 1 healthcare services to a patient and shall not include separate care 2 coordination activities undertaken by a payor. 3 (4) "Primary care services" means services provided in an outpatient, 4 non-emergency setting by or under the supervision of a physician, nurse 5 practitioner, physician assistant, or midwife, who is practicing general 6 primary care in the following fields, including as evidenced by billing 7 and reporting codes: family practice; general pediatrics; primary care 8 internal medicine; primary care obstetrics; or primary care gynecology. 9 Behavioral or mental health and substance use disorder services are 10 included in primary care services when integrated into a primary care 11 setting, including when provided by a behavioral healthcare psychia- 12 trist, social worker or psychologist. Primary care services shall not 13 include inpatient services, emergency department services, ambulatory 14 surgical center services, or services provided in an urgent care setting 15 that are billed with non-primary care billing and reporting codes. 16 (5) "Primary care spending" means any expenditure of funds made by 17 third party payors, public entities, or the state, for the purpose of 18 paying for primary care services directly or paying to improve the 19 delivery of primary care. Primary care spending includes all payment 20 methods, such as fee-for-service, capitation, incentives, value-based 21 payments or other methodologies, and all non-claim payments including 22 but not limited to incentive payments and care coordination payments. 23 For payees that own and/or operate facilities, entities, or other 24 providers, such as health systems or hospital systems, that provide 25 other medical services in addition to primary care, only those funds 26 that are separately documented as funds designated for primary care 27 services shall be considered primary care spending. Any spending shall 28 be adjusted appropriately to exclude any portion of the expenditure that 29 is reasonably attributed to inpatient services or other non-primary care 30 services. 31 (b) Reporting. (1) Beginning on April first, two thousand twenty-five, 32 each plan or payor as defined in this section shall annually report to 33 the department the percentage of the plan or payor's overall annual 34 healthcare spending that constituted primary care spending. 35 (2) Nothing herein shall require any plan or payor to report or 36 publicly disclose any specific rates of reimbursement for any specific 37 primary care services. 38 (3) No plan or payor shall require any healthcare provider to provide 39 additional data or information in order to fulfill this reporting 40 requirement. 41 (c) Regulation and publication. (1) The commissioner of health and the 42 superintendent shall each promulgate consistent regulations to carry out 43 the provisions of this section, including but not limited to setting 44 deadlines for the reporting required in this section, and adopting 45 further specific definitions of the primary care services for which 46 costs must be reported under this section, including specific billing 47 and reporting codes. 48 (2) The department of health and the department shall together provide 49 an annual report to the legislature with a summary of the primary care 50 spending data required in this section, and shall also make the report 51 publicly available on both agencies' websites, no later than three 52 months after the data has been collected. The first annual report shall 53 provide the spending information without identifying any individual 54 payor or plan's primary care spending. Each year thereafter, the report 55 spending data shall be published including information specific to each 56 plan or payor. 
 A. 1915 3 1 (d) Primary care spending. (1) Beginning on April first, two thousand 2 twenty-six, each plan or payor that reports less than twelve and one- 3 half percent of its total expenditures on physical and mental health is 4 primary care spending, as defined by this section, shall additionally 5 submit to the superintendent a plan to increase primary care spending as 6 a percentage of its total overall healthcare spending by at least one 7 percent each year. Beginning on April first, two thousand twenty-seven 8 and on April first of every subsequent year after such plan has been 9 submitted, and until such time as the plan or payor's reported primary 10 care spending is equal to or more than twelve and one-half percent of 11 that plan or payor's overall healthcare spending, the plan or payor's 12 annual reporting shall include information regarding steps that have 13 been taken to increase its proportion of primary care spending. 14 (2) The commissioner of health and the superintendent may jointly 15 issue guidelines or promulgate regulations regarding the areas on which 16 primary care spending could be increased, including but not limited to: 17 (A) reimbursement; 18 (B) capacity-building, technical assistance and training; 19 (C) upgrading technology, including electronic health record systems 20 and telehealth capabilities; 21 (D) incentive payments, including but not limited to per-member-per- 22 month, value-based-payment arrangements, shared savings, quality-based 23 payments, risk-based payments; and 24 (E) transitioning to value-based-payment arrangements. 25 (e) Limits on premium increases. Plans or payors shall adopt strate- 26 gies that improve value and quality of care and shift current spending 27 without increasing total medical expenditures. Spending shifts resulting 28 from compliance with this section shall not result in higher premiums or 29 cost-sharing requirements for insured individuals. 30 § 2. The social services law is amended by adding a new section 368-g 31 to read as follows: 32 § 368-g. Primary care spending. 1. Definitions. As used in this 33 section the terms "overall healthcare spending", "plan or payor", 34 "primary care", "primary care services" and "primary care spending" 35 shall have the same meanings as such terms are defined in section thir- 36 ty-two hundred seventeen-k of the insurance law. 37 2. Reporting. (a) Beginning on April first, two thousand twenty-five, 38 each Medicaid managed care provider under section three hundred sixty- 39 four-j of this title and any payor that provides coverage through Medi- 40 caid fee-for-service, as such term is defined in paragraph (e) of subdi- 41 vision thirty-eight of section two of this chapter, shall annually 42 report to the department the percentage of the provider's overall annual 43 healthcare spending that constituted primary care spending. 44 (b) Nothing herein shall require any Medicaid managed care provider to 45 report or publicly disclose any specific rates of reimbursement for any 46 specific primary care services. 47 (c) No Medicaid managed care provider shall require any healthcare 48 provider to provide additional data or information in order to fulfill 49 this reporting requirement. 50 3. Primary care spending. (a) Beginning on April first, two thousand 51 twenty-six, and in each subsequent year, each Medicaid managed care 52 provider under section three hundred sixty-four-j of this title and any 53 payor that provides coverage through Medicaid fee-for-service, as such 54 term is defined in paragraph (e) of subdivision thirty-eight of section 55 two of this chapter, that reports less than twelve and one-half percent 56 of its total expenditures on physical and mental health are on primary 
 A. 1915 4 1 care spending shall additionally submit to the commissioner a plan to 2 increase primary care spending as a percentage of its total overall 3 healthcare spending by at least one percent each year. Beginning on 4 April first, two thousand twenty-seven, and in each subsequent year 5 thereafter, until twelve and one-half percent of that provider or 6 payor's expenditures are on primary care spending, the payor or provid- 7 er's annual reporting under this section shall include information on 8 steps that have been taken to increase their proportion of primary care 9 spending. 10 (b) The commissioner and the superintendent of financial services may 11 jointly issue guidelines or promulgate regulations regarding the areas 12 on which spending could be increased, including but not limited to: 13 (i) reimbursement; 14 (ii) capacity-building, technical assistance and training; 15 (iii) upgrading technology, including electronic health record systems 16 and telehealth capabilities; 17 (iv) incentive payments, including but not limited to per-member-per- 18 month, value-based-payment arrangements, shared savings, quality-based 19 payments, risk-based payments; and 20 (v) transitioning to value-based-payment arrangements. 21 (c) The provisions of this section are subject to compliance with all 22 applicable federal and state laws and regulations, including the Centers 23 for Medicare and Medicaid Services approved Medicaid state plan. To the 24 extent required by federal law, the commissioner shall seek any federal 25 approvals necessary to implement this section, including, but not limit- 26 ed to, any state-directed payments, permissions, state plan amendments 27 or federal waivers by the federal Centers for Medicare and Medicaid 28 Services. The commissioner may also apply for appropriate waivers or 29 state directed payments under federal law and regulation or take other 30 actions to secure federal financial participation to assist in promoting 31 the objectives of this section. 32 4. Limits on cost increases. Plans or payors shall adopt strategies 33 that improve value and quality of care and shift current spending with- 34 out increasing total medical expenditures. 35 § 3. This act shall take effect immediately.