NY Ins L § 1121 (2021)
2021 New York Laws ISC - Insurance Article 11 - Licensing of Insurers 1121 - Voucher Insurance Program.

§  1121.    Voucher  insurance  program.  (a) The superintendent, in consultation with the commissioner of health, is authorized to conduct a program on a demonstration  basis  to  the  extent  of  funds  available therefor,  through contractual arrangements with approved organizations, to assist individuals and families residing in specified urban, rural or suburban areas in purchasing  health  care  coverage  through  insurers, health maintenance organizations and integrated delivery systems.  (b)  The  superintendent  shall designate the urban, rural or suburban areas to be served by the voucher insurance program.  The superintendent shall determine the overall  amount  of  funding  to  be  allocated  for vouchers issued in designated urban, rural or suburban areas.  (c)  The  superintendent,  in  consultation  with  the commissioner of health, shall establish guidelines for the submission  of  proposals  by organizations  for  the  purposes of administering the voucher insurance program including, but not limited to the following:  (1) standards for enrollment of eligible persons, including mechanisms for determining eligibility, and annual recertification;  (2) standards for  monitoring  the  performance  of  insurers,  health maintenance  organizations and integrated delivery systems participating in the voucher program; and  (3) such other criteria which may be deemed necessary.  (d) A proposal submitted by an organization to administer the  voucher program shall include the following:  (1) a designation of the geographic area to be served;  (2)  an  estimation  of the number of persons who will be eligible for the program and the estimated  number  of  actual  participants  in  the program in the specified geographic area;  (3)  a  description  of  the  procedures  for  enrollment  of eligible individuals and families in the voucher program;  (4) a demonstration of the availability and accessibility  of  offices where  individuals  and  families could obtain information and enroll in the voucher program;  (5)  a  description  of  the  mechanisms  for  preventing   fraudulent enrollment;  (6) a description of the procedure for issuance of the voucher and for monitoring  individual  and  family  enrollment  in  health  maintenance organizations, integrated delivery systems and insurers participating in the voucher program;  (7) a description of the mechanisms for monitoring the performance  of health   maintenance  organizations,  integrated  delivery  systems  and insurers participating in the program;  (8) a description of the procedures for marketing the voucher  program and   the   proposed   community   outreach   activities  including  the identification of any subcontractor who will perform these activities;  (9) a  detailed  description  of  the  estimated  expenses,  including personnel costs and other types of administrative expenses which will be incurred in the development and implementation of the voucher program;  (10)  a  demonstration  of  the  applicant's  ability to meet the data analysis and reporting requirements of the program;  (11) a demonstration of the financial feasibility of the program; and  (12)  such  other  information  as   the   superintendent   may   deem appropriate.  (e)  The  superintendent,  in  consultation  with  the commissioner of health, shall make a determination whether  to  approve,  disapprove  or recommend modification to the proposal of an applicant to administer the voucher program.  (f)  An  organization approved to administer the voucher program shall submit reports to the superintendent in such form and at times as may be  required in order to facilitate evaluation of the operations and results of the voucher program.  (g)  The  superintendent  may  approve  more  than one organization to administer the voucher program in all or part of a geographic area.  (h) The superintendent shall determine  the  amount  of  funds  to  be allocated  to an approved organization to administer the voucher program within such funds which  are  available  for  purposes  of  the  voucher program.  (i)  The superintendent shall review the marketing, community outreach activities and recruitment efforts of an organization administering  the voucher   program  and  may  provide  financial  incentives  if  certain enrollment targets are met.  (j) An organization approved to administer the voucher program may  be subject  to  financial  penalties  established by the superintendent for violating  the  standards  of  the  voucher  program.      Organizations administering  the  program shall also be required to repay to the state all voucher payments issued on  account  of  ineligible  individuals  or families.    An  organization approved to administer the voucher program may be removed by the superintendent as  an  approved  organization  and must  cooperate  in the orderly transition of services to other approved organizations.   The superintendent shall  provide  due  notice  and  an opportunity   for  a  hearing  to  an  approved  organization  prior  to implementing this subsection.  (k) Vouchers shall be issued by  the  organization  administering  the voucher  program  to  eligible  individuals  and  families  residing  in designated urban, suburban or rural areas.    Individuals  and  families shall   submit  such  vouchers  to  participating  insurers,  integrated delivery systems and health maintenance organizations for the purpose of obtaining insurance coverage.  (l) The superintendent shall  establish,  for  those  individuals  and families eligible, the voucher amounts by regulation, and shall consider household  size,  gross annual income, the cost of obtaining health care coverage through a participating insurer, integrated delivery system  or health  maintenance  organization  and overall funding available for the voucher program.  (m) An insurer  organized  to  write  the  kind  of  health  insurance specified  in  paragraph three of subsection (a) of section one thousand one hundred thirteen of  this  article,  and  a  corporation  or  health maintenance  organization  authorized pursuant to article forty-three of this chapter or a health maintenance organization or integrated delivery system certified pursuant to article forty-four of the public health law may submit a proposal for participation in the voucher  program  to  the superintendent  who shall consult with the commissioner of health.  Such proposal shall include:  (1)  a  description  of  the  standards  for  provider  enrollment  if applicable;  (2)  a description of the geographic area to be served, an estimate of the eligible and  actual  enrollees  in  such  designated  area;  and  a demonstration of the benefits to the community;  (3)  a  demonstration of access to and delivery of high quality health care services and, if  applicable,  that  any  network  of  health  care providers  includes  sufficient  numbers  of  geographically  accessible providers to service program participants;  (4) a demonstration of the manner in which primary and preventive care and medical treatment will be emphasized  or  substituted  for  hospital inpatient   or   emergency  room  services  in  order  to  provide  more appropriate care and more cost effective use of general hospitals.  (5) a description of the procedures  for  marketing  the  program,  if applicable;  (6) a description of health care provider payment methodologies;  (7) a description of the premium in relation to the benefit package;  (8)  a description of the estimated expenses including personnel costs and other types of administrative expenses which will be incurred in the program;  (9) a description of the  quality  assurance  and  utilization  review mechanisms to be implemented;  (10)  a  description  of  the provisions for arranging for or offering conversion coverage in the event of termination of coverage;  (11) a demonstration of an ability to meet data analysis and reporting requirements of the program; and  (12)  such  other  information  as   the   superintendent   may   deem appropriate.  (n)  The  superintendent,  in  consultation  with  the commissioner of health, shall make a determination whether  to  approve,  disapprove  or recommend  a  modification to an insurer's, integrated delivery system's or health maintenance organization's  proposal  to  participate  in  the voucher program.  (o)  The  superintendent,  in  consultation  with  the commissioner of health, shall ensure, to the extent possible, that the  voucher  program is  available  in  designated  urban,  suburban  or  rural  areas.   The superintendent may approve more than one  insurer,  integrated  delivery system  or  health  maintenance  organization  to serve all or part of a geographic area.  (p)  An  approved  insurer,  integrated  delivery  system  or   health maintenance  organization shall submit reports to the superintendent and to the organization administering the voucher program in such  form  and at  times  as  may  be  reasonably  required  in  order  to evaluate the operations and results of such program.  (q)  An  approved  insurer,  integrated  delivery  system  or   health maintenance  organization  may  be  removed  from  participation  in the voucher program provided, however, that eligible persons shall  continue to  receive  coverage  of  services  until  such  time  as  the  orderly transition to other approved insurers, integrated delivery  systems  and health  maintenance  organizations  can be effected.  The superintendent shall provide due notice and an opportunity for a hearing to an approved insurer, integrated delivery systems or health maintenance  organization prior to implementing this subsection.  (r) Notwithstanding any inconsistent provision of law or regulation to the  contrary,  benefits  under  the voucher program shall be considered secondary to any other plan of insurance or benefit program under  which a person may have coverage.  (s)  An  insurer,  integrated  delivery  system  or health maintenance organization  may  issue  contracts  approved  by  the   superintendent, providing  coverage  to  voucher  recipients,  pursuant to the following criteria:  (1) the provisions are not misleading or confusing:  (2) the provisions are  consistent  with  the  needs  of  the  voucher program;  (3)  the materials describing the contract fully and clearly state the benefits and limitations of such contract;  (4) the  duration  of  such  contracts  and  the  extent  of  exposure thereunder  by  insurers,  article  forty-three corporations, integrated delivery systems or health maintenance organizations shall be determined by the superintendent;  (5) the contract is a reasonable and appropriate  approach  to  expand the availability of health care coverage;  (6) the funding for the contract is reasonably related to the benefits provided and sufficient to support the contract;  (7)   any  such  contracts  must  include  the  preexisting  condition provisions permitted by section three thousand  two  hundred  thirty-two and  section  four  thousand  three  hundred eighteen of this chapter as applicable; and  (8) notwithstanding any provisions of this chapter  to  the  contrary, the  superintendent  may waive, modify or suspend any provisions of this chapter, except as to mandatory benefits, or department  regulations  as applicable to the insurers, article forty-three corporations, integrated delivery   systems  or  health  maintenance  organizations  which  issue coverage pursuant to this section, provided such waiver, modification or suspension is based on the following:  (A) any waiver, modification  or  suspension  of  provisions  of  this chapter  or  department regulations is essential to the operation of the voucher program and to the rational development of programs  to  provide health care coverage or equivalent coverage mechanisms to the uninsured; and  (B)  any  waiver,  modification  or  suspension  of provisions of this chapter or department regulations will not impair  the  ability  of  the insurer,  article forty-three corporation, integrated delivery system or health maintenance organization to satisfy its existing and  anticipated contracts  and  other  obligations,  including  such  standards  as  the superintendent shall prescribe concerning adequate capital and financial requirements.  (t) The contracts issued by insurers, integrated delivery  systems  or health  maintenance  organizations  and  approved  by the superintendent providing coverage to voucher  recipients  must  provide  for  only  the following covered services:  (1) Outpatient diagnostic X-ray and lab services;  (2) Outpatient surgical services including anesthesia;  (3) Mammography screening.  (4) Cervical cytology screening.  (5) Well-child care from birth.  (6) Primary and preventive care services.  (u)  In  order  to  be eligible to purchase coverage under the voucher program, the individual or family shall meet the following criteria:  (1) reside or resides in a household having a gross  household  income at  or  below  two  hundred  twenty-two  percent of the non-farm federal poverty level (as defined and annually revised by the federal office  of management  and  budget).    An  applicant  shall  provide the necessary documentation  to  initially,   and   annually   thereafter,   determine eligibility  for a voucher.  Such documentation shall include the latest annual income tax return.  If no such income tax return has  been  filed or  if  the  household  income has changed since the date of the return, such documentation shall also include, but not be limited to:   paycheck stubs;  written  documentation  of  income  from all employers; or other documentation of income  (earned  or  unearned)  as  determined  by  the superintendent, provided however, such documentation shall set forth the source of such income;  (2)  is  not  eligible  for  medical  assistance under title eleven of article five of the social services law  or  for  medicare  pursuant  to title eighteen of the federal social security act;  (3)  does  not  have equivalent health care coverage as defined by the superintendent.  The applicant shall attest to the source and nature  of health care coverage available;  (4) is a resident of a designated urban, suburban or rural area in New York state.  Such residency shall be demonstrated by adequate proof of a New  York  state  street  address  or if the individual or family has no street address, then by other such proof;  (5)  has  not  had  equivalent  health care coverage within the twelve month period prior to application for a voucher.  This limitation  shall not  apply  to  persons  who became ineligible for medical assistance or whose insurance terminated as a result of loss of employment within such period;  (6)  the  individual  or  family   shall   notify   the   organization administering  the  voucher program within sixty days, of any changes in income, health care coverage or residency that may make them  ineligible for the voucher program; and  (7)  any individual or family who, with the intent to obtain benefits, willfully misstates income or residence or other health care coverage to establish eligibility or  willfully  fails  to  notify  an  organization administering  the voucher program of an increase in income or change in residence or health care coverage which may disqualify the individual or family for benefits shall repay such subsidy.   Individuals  seeking  to enroll  in  the  voucher  program  shall  be informed that such willfull misstatement or failure to notify shall result in such liability.  (v) Nothing in this section shall be construed to provide a  right  or entitlement  to  insurance  coverage,  or  a cause of action or right of action to eligible individuals and families, approved organizations,  or providers  of  health  care services for the provision of or payment for such  services  relating  to  the  availability  or  implementation   of insurance coverage under this section.  (w) The superintendent shall implement such requirements or procedures as necessary to prevent, detect and deter fraud and abuse in the voucher insurance program.