NY Pub Health L § 2511 (2021)
2021 New York Laws PBH - Public Health Article 25 - Maternal and Child Health Title 1-A - Child Health Insurance Plan 2511 - Child Health Insurance Plan.

§  2511.  Child  health  insurance  plan  1.  (a) The commissioner, in consultation with the superintendent, shall establish a program  to  the extent of funds available therefor through contractual arrangements with approved  organizations to provide covered health care services coverage for eligible children. The availability  of  coverage  for  primary  and preventive  health  care  services  and  inpatient  health care services coverage shall be continued pending approval of contractual arrangements that include covered health care services coverage and implementation of such coverage to the extent of funds available therefor.  (b) Coverage for covered health care services shall not  be  effective until  such  time  as  contractual arrangements are executed pursuant to this section for such purposes and an eligible child is enrolled in  the program.   2.  In  order  to  be  eligible  for  a  subsidy  payment  pursuant to subdivision three of this section, a  child  shall  meet  the  following criteria:  (a) (i) effective January first, nineteen hundred ninety-nine, resides in  a  household  having  a net household income at or below one hundred ninety-two percent of the non-farm federal poverty level (as defined and updated by the United States department of health and human services) or the gross equivalent of such net income; and  (ii) effective July first, two thousand, resides in a household having a gross household income at or below two hundred fifty  percent  of  the non-farm  federal  poverty  level  (as defined and updated by the United States department of health and human services); and  (iii) effective September first, two  thousand  eight,  resides  in  a household  having a household income at or below four hundred percent of the non-farm federal poverty level (as defined and updated by the United States department of health and human services);  (b) is not eligible for medical assistance, except that  a  child  who becomes eligible for medical assistance after becoming an eligible child under  this  title,  may  be  eligible for a subsidy payment pursuant to subdivision three of this section as medical assistance for a period  up to three months after becoming eligible for medical assistance; and  (c)  does not have health care coverage under insurance, as defined by the commissioner, in consultation with the superintendent. The applicant for insurance shall attest to the  source  and  nature  of  the  child's health care coverage under this paragraph, if any; and   * (e)  is  a  resident  of  New  York  state.  Such residency shall be demonstrated by adequate proof, as determined by the commissioner, of  a New  York state street address. If the child has no street address, such proof may include, but not  be  limited  to,  school  records  or  other documentation determined by the commissioner.   * NB  Effective until January 1, 2014 or a later date to be determined by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)   * (e) is a resident  of  New  York  state.  Such  residency  shall  be attested  to  by  the  applicant  for  insurance,  provided however, the commissioner shall require adequate proof of a  New  York  state  street address  in  circumstances when there is an inconsistency with residency information from other data sources.   * NB Effective January 1, 2014 or a later date to be determined by the commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)  (f)  * (i)  In  order  to  establish  income  eligibility  under  this subdivision  at  initial  application,  a  household  shall provide such documentation specified in subparagraph  (iii)  of  this  paragraph,  as necessary  and  sufficient  to determine a child's financial eligibility for a subsidy payment under this title. The commissioner may verify  the accuracy  of  such  income  information  provided  by  the  household by  matching it against income information contained in databases  to  which the commissioner has access, including the state's wage reporting system pursuant to subdivision five of section one hundred seventy-one-a of the tax  law  and by means of an income verification performed pursuant to a cooperative agreement  with  the  department  of  taxation  and  finance pursuant to subdivision four of section one hundred seventy-one-b of the tax law.   * NB  Effective until January 1, 2014 or a later date to be determined by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)   * (i) In order to establish income eligibility under this  subdivision at  initial  application,  a household shall provide the social security numbers for each parent and legally responsible adult who is a member of the household, subject  to  subparagraph  (v)  of  this  paragraph.  The commissioner  shall  determine  eligibility  based on income information contained in databases to which the commissioner has  access,  including the  state's  wage  reporting  system  pursuant  to  subdivision five of section one hundred seventy-one-a of the tax law  and  by  means  of  an income  verification  performed pursuant to a cooperative agreement with the department of taxation and finance pursuant to subdivision  four  of section one hundred seventy-one-b of the tax law. The commissioner shall require  an  attestation  by  the  household that the income information obtained from electronic data  sources  is  accurate.  Such  attestation shall  include  any other household income information not obtained from an electronic data source that  is  necessary  to  determine  a  child's financial  eligibility  for  a  subsidy payment under this title. If the attestation is reasonably  compatible  with  information  obtained  from available  data  sources,  no  further  information  or documentation is required.  If  the  attestation  is  not  reasonably   compatible   with information obtained from available data sources, documentation shall be required as specified in subparagraph (iii) of this paragraph.   * NB Effective January 1, 2014 or a later date to be determined by the commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)  (ii)  In  order to establish income eligibility under this subdivision at recertification, the  commissioner  may  make  a  redetermination  of eligibility without requiring information from the individual if able to do  so  based  on  reliable  information  contained  in the individual's enrollment file or other more current information contained in databases to which  the  commissioner  has  access,  including  the  state's  wage reporting  system  and  by  means  of  an  income verification performed pursuant to a cooperative agreement with the department of taxation  and finance   pursuant   to   subdivision   four   of  section  one  hundred seventy-one-b  of  the  tax  law.  The  commissioner  shall  require  an attestation  by  the  household that the income information contained in the  enrollment  file  or  obtained  from  electronic  data  sources  is accurate.  Such  attestation  shall  include  any other household income information  not  obtained  from  an  electronic  data  source  that  is necessary  to  redetermine a child's financial eligibility for a subsidy payment under this title. In the event that there  is  an  inconsistency between  the  income  information  attested  to by the household and any information obtained by the commissioner from other sources pursuant  to this subparagraph, and such inconsistency is material to the household's eligibility  for  a  subsidy  payment under this title, the commissioner shall require the household to provide income documentation as specified in subparagraph (iii) of this paragraph.   * (iii) Income documentation shall include, but not be limited to, one or more of the following for each parent and legally  responsible  adult who  is  a  member of the household and whose income is available to the child;  (A) current annual income tax returns;  (B) paycheck stubs;  (C) written documentation of income from all employers; or  (D) written documentation of income eligibility of a child for free or reduced  breakfast or lunch through the school meal program certified by the child's school, provided that:  (I) the commissioner  may  verify  the  accuracy  of  the  information provided in the same manner and way as provided for in subparagraph (ii) of this paragraph; and  (II)  such  documentation  may  not be suitable proof of income in the event of a material inconsistency in income after the  commissioner  has performed  verification pursuant to subparagraph (ii) of this paragraph; or  (E) other documentation of income (earned or unearned)  as  determined by  the  commissioner,  provided,  however, such documentation shall set forth the source of such income.   * NB Effective until January 1, 2014 or a later date to be  determined by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)   * (iii)   If   the   attestation   of  household  income  required  by subparagraphs  (i)  and  (ii)  of  this  paragraph  is  not   reasonably compatible   with   information  obtained  from  data  sources,  further information,  including  documentation,  shall   be   required.   Income documentation  shall  include, but not be limited to, one or more of the following for each parent and legally responsible adult who is a  member of the household and whose income is available to the child;  (A) current annual income tax returns;  (B) paycheck stubs;  (C) written documentation of income from all employers; or  (D) written documentation of income eligibility of a child for free or reduced  breakfast or lunch through the school meal program certified by the child's school, provided that:  (I) the commissioner  may  verify  the  accuracy  of  the  information provided in the same manner and way as provided for in subparagraph (ii) of this paragraph; and  (II)  such  documentation  may  not be suitable proof of income in the event of a material inconsistency in income after the  commissioner  has performed  verification pursuant to subparagraph (ii) of this paragraph; or  (E) other documentation of income (earned or unearned)  as  determined by  the  commissioner,  provided,  however, such documentation shall set forth the source of such income.   * NB Effective January 1, 2014 or a later date to be determined by the commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)   * (iv) In the event a household does not provide income  documentation required  by  subparagraph  (iii) of this paragraph within two months of the approved organization's request,  the  approved  organization  shall disenroll  the  child  at  the  end  of such two month period. Except as provided in  paragraph  (c)  of  subdivision  five-a  of  this  section, approved  organizations shall not be obligated to repay subsidy payments made by the state on behalf of children enrolled during this  two  month period.   * NB  Effective until January 1, 2014 or a later date to be determined by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)   * (iv) In the event a household does not provide income  documentation required  by  subparagraph  (iii) of this paragraph within two months of the  approved  organization's  or  state  enrollment  center's  request, whichever  is  applicable, the approved organization or state enrollment center shall disenroll the child at the end of such  two  month  period.  Except  as  provided  in  paragraph  (c)  of  subdivision five-a of this section, approved organizations shall not be obligated to repay  subsidy payments  made  by  the state on behalf of children enrolled during this two month period.   * NB Effective January 1, 2014 or a later date to be determined by the commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)   * (v)  In  the  event  a  household  chooses not to provide the social security numbers required by subparagraph (ii) of this  paragraph,  such household  shall  provide income documentation specified in subparagraph (iii) of this paragraph  as  a  condition  of  the  child's  enrollment. Nothing  in  this paragraph shall be construed as obligating a household to provide social security numbers of  parents  or  legally  responsible adults  as  a  condition  of  a  child's enrollment or eligibility for a subsidy payment under this title.   * NB Effective until January 1, 2014 or a later date to be  determined by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)   * (v)  In  the  event  a  household  chooses not to provide the social security  numbers  required  by  subparagraphs  (i)  and  (ii)  of  this paragraph,  such  household shall provide income documentation specified in subparagraph (iii) of this paragraph as a condition  of  the  child's enrollment. Nothing in this paragraph shall be construed as obligating a household  to  provide  social  security  numbers  of parents or legally responsible adults as a condition of a child's enrollment or eligibility for a subsidy payment under this title.   * NB Effective January 1, 2014 or a later date to be determined by the commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)   * (vi) Any income verification response by the department of  taxation and  finance  pursuant  to  subparagraphs (i) and (ii) of this paragraph shall not  be  a  public  record  and  shall  not  be  released  by  the commissioner,  the  department  of  taxation  and finance or an approved organization except pursuant to this  paragraph.  Information  disclosed pursuant to this paragraph shall be limited to information necessary for verification. Information so disclosed shall be kept confidential by the party  receiving  such  information.  Such information shall be expunged within a reasonable time to be determined by the  commissioner  and  the department of taxation and finance.   * NB  Effective until January 1, 2014 or a later date to be determined by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)   * (vi) Any income verification response by the department of  taxation and  finance  pursuant  to  subparagraphs (i) and (ii) of this paragraph shall not  be  a  public  record  and  shall  not  be  released  by  the commissioner,  the  department  of  taxation  and  finance,  an approved organization, or the state enrollment center, except  pursuant  to  this paragraph.  Information  disclosed  pursuant  to this paragraph shall be limited  to  information  necessary  for  verification.  Information  so disclosed  shall  be  kept  confidential  by  the  party  receiving such information. Such information shall be expunged within a reasonable time to be determined by the commissioner and the department of taxation  and finance.   * NB Effective January 1, 2014 or a later date to be determined by the commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)   * (g)  (i)  Notwithstanding  any  inconsistent provision of law to the contrary  and  subject  to  the  availability   of   federal   financial participation  under  title  XIX  of  the federal social security act, a child under the age of nineteen shall be presumed  to  be  eligible  for subsidy payments and temporarily enrolled for coverage under this title, once  during  a  twelve  month period, beginning on the first day of the enrollment period following  the  date  that  an  approved  organization  determines,  on the basis of preliminary information, that a child's net household income does not exceed the income  level  specified  in  title eleven  of article five of the social services law for children eligible for  medical  assistance  based  on  such  child's  age.  The  temporary enrollment period shall continue  until  the  earlier  of  the  date  an eligibility determination is made pursuant to this title or title eleven of article five of the social services law, or two months after the date temporary  enrollment  begins;  provided however, a temporary enrollment period may be extended in the event an eligibility  determination  under this title or title eleven of article five of the social services law is not  made within such two month period through no fault of the applicant for insurance for medical assistance. The commissioner shall assure that children who  are  enrolled  pursuant  to  this  paragraph  receive  the appropriate  follow-up  for  a determination of eligibility for benefits under this title or title eleven of article five of the social  services law  prior  to  the  termination of the temporary enrollment period. The commissioner shall assure that children and their families are  informed of all available enrollment sites in accordance with subdivision nine of this section.  (ii)  Effective  September  first  two  thousand  seven, through March thirty-first, two thousand fourteen  temporary  enrollment  pursuant  to subparagraph  (i)  of  this paragraph shall be provided only to children who apply for recertification of coverage under this title who appear to be eligible for medical assistance under title eleven of article five of the social services law.   * NB Expires July 1, 2023   * (h) The commissioner may, in consultation with  the  superintendent, promulgate rules and regulations necessary to prevent fraud and abuse in eligibility  determinations  made  by approved organizations pursuant to this subdivision.   * NB Expires July 1, 2023  (i)  Notwithstanding  any  inconsistent  provision  of  law,  rule  or regulation:  (i)  A  newborn  child who meets the eligibility criteria set forth in this subdivision or subdivision five of this section, as  determined  by an  approved  organization or the health insurance exchange marketplace, whichever is applicable, shall be enrolled retroactively  to  the  first day of the month in which the child is born, provided that the applicant for  insurance  submits  a completed and signed application and required information and documentation within sixty days of the child's birth.  (ii) A newborn child shall be presumed eligible for  subsidy  payments under  this  subdivision or eligible for coverage under subdivision five of this section, provided that the applicant  for  insurance  submits  a completed and signed application within sixty days of the child's birth. Once  eligibility  is  determined  by  the  approved organization or the health insurance exchange marketplace, whichever is applicable,  on  the basis   of   preliminary   information,  the  child  shall  be  enrolled retroactively to the first day of the month in which the child is  born. All  other  procedures  and  standards  regarding presumptive enrollment applicable to eligible children enrolled under this title and  specified in  state  contracts  with  approved organizations or implemented by the health insurance exchange marketplace, whichever  is  applicable,  shall apply to presumptive enrollment of newborn children.  (j)  Where  an  application for recertification of coverage under this title contains insufficient information for  a  final  determination  of eligibility  for  continued coverage, a child shall be presumed eligible for a period not  to  exceed  the  earlier  of  two  months  beyond  the preceding  period  of  eligibility  or  the  date  upon  which  a  final  determination  of  eligibility  is  made  based  on  the  submission  of additional  data.  In  the  event  such  additional  information  is not submitted within two months of  the  approved  organization's  or  state enrollment  center's  request,  whichever  is  applicable,  the approved organization or  state  enrollment  center  shall  disenroll  the  child following the expiration of such two month period. Except as provided in paragraph   (c)   of   subdivision  five-a  of  this  section,  approved organizations shall not be obligated to repay subsidy payments  received on behalf of children enrolled during this two month period.   2-a. (a) An approved organization that has reasonable cause to believe that an applicant for insurance, parent or legally responsible adult has provided  false  income information may submit tax returns and any other available income information, including, if not  prohibited  by  federal law  for  purposes  of  income  verification,  social  security  account numbers, to the department as  may  be  necessary  to  determine  income eligibility.  The department shall promptly furnish to the department of taxation  and  finance,  pursuant  to  the  agreements   authorized   by subdivision  five  of  section one hundred seventy-one-a and subdivision four of section one hundred seventy-one-b of the  tax  law,  the  names, address  and  social  security  account  numbers,  if  available, of the parents and legally responsible adults who are members of the household, together with a request that the department  of  taxation  and  finance, pursuant to those agreements, promptly ascertain insofar as is possible, and  from  the most recent available data, whether the collective income reported by those individuals exceeds the income eligibility  level  for that  household,  as  determined  by  the  department in compliance with paragraph (a) of subdivision two of this  section.  The  department,  in consultation   with  the  department  of  taxation  and  finance,  shall establish  a  methodology  for  comparing  numerical   equivalents.   In ascertaining whether a household's income exceeds the income eligibility threshold  transmitted by the department, the department of taxation and finance shall also examine information available pursuant to section one hundred seventy-one-a of the tax law where any of the named  individuals have  failed  to  file  a  New York state income tax return for the most recent filing year or where there is an indication, from the  department or otherwise, that the individual's income may have changed. Reliance on such  section  one  hundred seventy-one-a information shall be specially indicated in the department of taxation  and  finance's  response.  This provision shall not be construed to authorize the department of taxation and  finance  to  disclose any figure on any personal income tax return. The department shall promptly inform the approved  organization  of  the response  from  the  department  of  taxation and finance. Submission of income information for verification shall not delay the  application  of any  other provision of this section to an applicant for insurance or an enrolled child.  (b) Before an approved organization submits income information to  the department for verification with the department of taxation and finance, it shall:  (i)  provide  the  applicant  for  insurance  with notification of its intent to seek such verification;  (ii) notify the applicant for insurance  of  the  confidentiality  and expungement  provisions  contained in paragraph (c) of this subdivision; and  (iii) provide the applicant for  insurance  with  the  opportunity  to review and modify the income information.  (c)   Such   income  information  and  verification  response  by  the department of taxation and finance shall not  be  a  public  record  and shall  not be released by the department, the department of taxation and  finance  or  the  approved  organization   except   pursuant   to   this subdivision.    Information  disclosed pursuant to this section shall be limited  to  information  necessary  for  verification.  Information  so disclosed  shall  be  kept  confidential  by  the  party  receiving such information.  Such  income  information  shall  be  expunged  within   a reasonable time to be determined by the department and the department of taxation and finance.   2-b.  (a)  For  purposes  of  claiming federal financial participation under paragraph nine of subsection (c)  of  section  twenty-one  hundred five of the federal social security act, a household shall provide:  (i) the social security number for the applicant to be verified by the commissioner  in  accordance  with  a  process established by the social security administration pursuant to federal law, or  (ii) documentation  of  citizenship  and  identity  of  the  applicant consistent  with  requirements  under the medical assistance program, as specified by the commissioner on the initial application.  (b) Pending receipt of the information required by subparagraph (i) of paragraph (a) of this subdivision, an initial application shall continue to be processed by an approved organization  or  enrollment  facilitator and a child shall be presumptively enrolled in the program in accordance with procedures and timeframes currently specified in contracts.   2-c.  Express  lane  eligibility. (a) Notwithstanding any inconsistent provision of law, rule or regulation, the commissioner is authorized  to (i)  establish  standards and procedures for express lane enrollment and renewal implemented in accordance  with  section  2107(e)(1)(B)  of  the federal  social security act, including but not limited to reliance on a finding  made  by  an  express  lane  agency,  as  defined  in   section 1902(e)(13)(F)  of the federal social security act, to determine whether a child meets one or more of  the  eligibility  criteria  set  forth  in subdivision  two  of  this  section;  (ii)  specify  such  standards and procedures in the state child health plan established under title XXI of the federal social security act and applicable contracts  with  approved organizations   and   enrollment   facilitators;  and  (iii)  waive  any information and documentation requirements set  forth  in  this  section necessary  to  implement  express lane eligibility pursuant to standards and procedures established under subparagraphs  (i)  and  (ii)  of  this paragraph;   provided,   however,  that  information  and  documentation required pursuant to subdivision  two-b  of  this  section  may  not  be waived.  (b)  Subject  to federal approval, such standards and procedures shall specify that information and  documentation  regarding  citizenship  and immigration  status  collected by an express lane agency and provided to the commissioner for the purpose of express lane eligibility may be used to satisfy the requirements of subdivision two-b of this section.  (c) Such standards and procedures shall also  include  a  process  for determining  enrollment  error rates and implementing corrective actions as required by section 1902(e)(13)(E) of  the  federal  social  security act.   3.  Subsidy  payments  shall be made, pursuant to subdivision eight of this section, to approved organizations for the purposes of  subsidizing the  entire  cost of coverage for eligible children meeting the criteria of subdivision two of this  section.  Notwithstanding  any  inconsistent provision  of  this subdivision, the total annual aggregate cost-sharing with respect to all eligible children in a  family  under  this  section shall not exceed amounts provided pursuant to applicable federal law. In order  to be eligible for a subsidy payment pursuant to this subdivision a premium payment shall be paid for an eligible child in accordance with the provisions of subdivision nine of section twenty-five hundred ten of  this title. Nothing herein shall preclude  payment  of  the  premium  on behalf  of  an  eligible  child  on a monthly, quarterly, semi-annual or annual basis.   4.  Households  shall  report  to  the  approved organization or state enrollment center, whichever is  applicable,  within  thirty  days,  any changes  in  New  York  state  residency  or  health care coverage under insurance that may make a child ineligible for subsidy payments pursuant to this section. Any individual who, with the intent to obtain benefits, willfully  misstates  income  or  residence  to  establish   eligibility pursuant to subdivision two of this section or willfully fails to notify an  approved  organization  or  state  enrollment  center of a change in residence or health care coverage pursuant  to  this  subdivision  shall repay  such  subsidy  to the commissioner. Individuals seeking to enroll children for coverage shall be informed that such  willful  misstatement or failure to notify shall result in such liability.   4-a. Any individual who, with the intent to obtain benefits, willfully misstates  income  or  residence  to  establish  eligibility pursuant to subdivision two of this section or willfully fails to notify an approved organization of an increase in income or change in residence pursuant to subdivision two  of  this  section  shall  repay  such  subsidy  to  the commissioner.  Individuals seeking to enroll children for coverage shall be informed that such willful misstatement or failure  to  notify  shall result in such liability.   5.  Notwithstanding  any inconsistent provisions of subdivision two of this section, an individual who meets the criteria of paragraphs (b) and (c) of subdivision two of this section but not the criteria of paragraph (a) of  such  subdivision  may  be  enrolled  for  covered  health  care services,  provided  however, that an approved organization shall not be eligible to receive a subsidy payment for  providing  coverage  to  such individuals.   The   cost   of  coverage  shall  be  determined  by  the commissioner, in consultation with the superintendent and  shall  be  no more than the cost of providing such coverage.   5-a.  Obligations  of  approved  organizations or the state enrollment center.  (a)  An  approved  organization  or  state  enrollment  center, whichever  is  applicable,  shall  have  the  obligation  to  review all information provided pursuant to subdivision two  of  this  section  and shall not certify or recertify a child as eligible for a subsidy payment unless the child meets the eligibility criteria.  (b)  An approved organization or state enrollment center, whichever is applicable,  shall  promptly  review  all  information  relating  to   a potential  change  in eligibility based on information provided pursuant to subdivision four of this section. Within at least thirty  days  after receipt   of  such  information,  the  approved  organization  or  state enrollment center shall make a determination whether the child is  still eligible  for  a  subsidy payment and shall notify the household and the commissioner if it determines the child is not eligible  for  a  subsidy payment.  (c)  Any approved organization which engages in a pattern and practice of enrolling or recertifying children who  are  ineligible  pursuant  to subdivision  two  of this section, as determined by the commissioner, in consultation with the superintendent, shall be  required  to  repay  all subsidy  payments  received  on account of ineligible children. Improper enrollment based upon a  good  faith  reliance  on  documentation  which appears accurate on its face shall not constitute a pattern or practice. Any  such  approved  organization  may  also  be  removed as an approved organization, provided however, that eligible children shall continue to receive services until such time as  the  orderly  transition  to  other approved organizations can be effected.    6.  The  commissioner  shall, in consultation with the superintendent, establish  guidelines  for  the  submission  of  proposals  by  eligible organizations for the purposes of providing covered health care services coverage  to  eligible  children  including,  but  not  limited  to, the following components:  (a)  standards  for  individual  enrollment  including  mechanisms for presumptive eligibility and annual recertification;  (b) standards for provider enrollment;  (c) standards for scope of covered health care service benefits;  (d) standards for health care provider payment methodologies, provided however, that levels and methods of payment  shall  be  consistent  with those provided under similar insurance plans;  (e)  standards  for  appropriate utilization review, quality assurance and case management mechanisms; and  (f) such other criteria which may be deemed necessary.   6-a. The commissioner, in consultation with  the  superintendent,  may establish  a  program  for  cards  issued to eligible children which can store or access information electronically, including  the  identity  of the   child   and  such  other  medical  data  and  information  as  the commissioner, in consultation with the superintendent, may prescribe.   7. (a) A proposal submitted by an eligible organization shall meet the following criteria:  (i) designate the geographic area to be served  by  the  program,  and estimate  the number of eligible participants and actual participants in such designated area;  (ii) assure access  to  and  delivery  of  high  quality,  appropriate covered  health care services and, when applicable, include a network of health  care  providers  in  sufficient   numbers   and   geographically accessible to service program participants;  (iii)   describe   the   procedures   for  marketing  and  determining eligibility for the health care coverage plan in the  program  location, including  the  designation  of  other  entities  which may perform such functions under contract with the organization;  (iv) describe proposed health care provider payment methodologies;  (v) describe in detail the  estimated  expenses,  including  personnel costs  and other types of administrative expenses which will be incurred in the development and implementation of the program;  (vi) describe the  quality  assurance,  utilization  review  and  case management mechanisms to be implemented;  (vii)  demonstrate  the  applicant's ability to meet the data analysis and reporting requirements of the program;  (viii) describe the benefit package to be offered by the  program  and the cost of such benefit package;  (ix)  describe the provisions for arranging for or offering conversion coverage in the event of termination of coverage under this title;  (x) demonstrate financial feasibility of the program;  (xi) describe the premium, copayments and deductibles to  be  paid  by program participants who are ineligible for subsidy payments; and  (xii)  include  such  other  information  as  the commissioner and the superintendent may deem appropriate.  (b) The commissioner, in consultation with the  superintendent,  shall make  a  determination  whether  to  approve,  disapprove  or  recommend modification of the proposal. In order for a proposal to be approved  by the   commissioner,   the   proposal   must  also  be  approved  by  the superintendent with respect to the provisions  of  subparagraphs  (viii) through (xii) of paragraph (a) of this subdivision.  (c)  The  commissioner, in consultation with the superintendent, shall ensure, to  the  extent  possible,  that  child  health  insurance  plan  coverage  is  available  in  all  geographic areas. The commissioner may approve more than one approved organization to serve all or  part  of  a geographic area.   7-a.  (a)  Notwithstanding any inconsistent provisions of subdivisions one and three of section two thousand five hundred ten  of  this  title, subdivisions  six and seven of this section, subject to paragraph (b) of this subdivision, and section  one  hundred  sixty-three  of  the  state finance  law,  the commissioner may contract with organizations approved under section three hundred sixty-four-j of  the  social  services  law, without  a  competitive  bid or request for proposal process, to provide covered health care services coverage for eligible children pursuant  to this title.  (b)  In  order  to  be  approved  pursuant  to  this  subdivision,  an organization shall meet the criteria set forth in subdivision  seven  of this  section  and  shall  comply  with  standards  established  by  the commissioner, in  consultation  with  the  superintendent,  pursuant  to subdivision six of this section.  (c)  Organizations  approved pursuant to this subdivision shall comply with  the  requirements  of  this  title  and   contractual   provisions established thereunder, title XXI of the federal social security act and any  implementing federal regulations, and requirements set forth in the state child health plan established pursuant to title XXI of the federal social security act.  (d) Notwithstanding any inconsistent provision of section one  hundred twelve  or  one  hundred  sixty-three  of  the state finance law, at the discretion of the commissioner, without a competitive bid or request for proposal process, contractual arrangements with approved  organizations, as defined in subdivision two of section twenty-five hundred ten of this article,  in  effect in two thousand seven may be extended to any period on and after July first, two thousand seven to provide an  uninterrupted continuation of services and may be amended as deemed necessary.   8.  The  commissioner  shall  determine  the  amount  of  funds  to be allocated to an approved organization  for  the  purposes  described  in subdivision one of this section within such funds which may be available for  the purposes of this article. (a) Subsidy payments made to approved organizations on and after April first, two thousand five through  March thirty-first,  two  thousand  six, shall be at amounts approved prior to April first, two thousand five. Applications for  increases  to  subsidy payments submitted by approved organizations to the superintendent on or after  January  first,  two  thousand  five, shall not be considered for approval until after March thirty-first, two thousand six. (b)  Further, subsidy  payments  made  to  approved  organizations  on and after April first, two thousand  seven  through  March  thirty-first,  two  thousand eight,  shall  be at amounts approved prior to April first, two thousand seven. Applications for  increases  to  subsidy  payments  submitted  by approved  organizations to the superintendent on or after January first, two thousand seven, shall not be considered  for  approval  until  after March  thirty-first, two thousand eight. (c) Nothing in this subdivision shall prohibit decreases in subsidy payments in accordance with relevant contract provisions.  (d)(i) Effective April first, two thousand nine, payment for marketing and facilitated enrollment activities set forth in subdivision  nine  of this   section  and  included  in  subsidy  payments  made  to  approved organizations providing such services pursuant to a  contract  with  the state  shall  be  limited  to  an  amount  determined  annually  by  the commissioner.  (ii) Such subsidy payments shall be adjusted by  the  commissioner  to remove  any  costs  of  approved  organizations  in excess of the amount  determined in accordance with subparagraph (i) of this  paragraph  based on cost reports submitted to the department by approved organizations.  (f)  The  commissioner  shall adjust subsidy payments made to approved organizations on and after April  first,  two  thousand  eleven  through March thirty-first, two thousand twelve, so that the amount of each such payment is reduced by one and seven-tenths percent.  (g)  The  commissioner  may increase subsidy payments made to approved organizations that voluntarily participate in  the  multi-payor  patient centered  medical  home  program  to reflect additional costs associated with enhanced payments made  to  certified  medical  homes  by  approved organizations as required by article twenty-nine-AA of this chapter.  (h) Notwithstanding any inconsistent provision of this title, articles thirty-two  and  forty-three  of the insurance law and subsection (e) of section eleven hundred twenty of the insurance law, for the period April first, two thousand fourteen through March  thirty-first,  two  thousand fifteen,  subsidy  payments  made  to approved organizations shall be at amounts approved prior to April first, two thousand fourteen.   9. The commissioner shall, within amounts available therefor, contract with community-based and other marketing organizations for  purposes  of public  education,  outreach,  and  recruitment  of  eligible  children, including the distribution of  applications  and  information  regarding enrollment.  In awarding such contracts, the commissioner shall consider the  marketing,   outreach   and   recruitment   efforts   of   approved organizations,  and  the  extent to which such organizations are able to effectively target efforts in geographic regions where the proportion of eligible children enrolled under this title  are  lower  than  in  other geographic  regions  of  the  state. Community-based organizations shall include,  but  not  be  limited   to:   day   care   centers,   schools, community-based diagnostic and treatment centers, and hospitals.   10.  Notwithstanding  any  other law or agreement to the contrary, and except in the case of a child or children who also becomes eligible  for medical  assistance,  benefits  under  this  title  shall  be considered secondary to any other plan of insurance or benefit program, except  the children  and  youth  with  special  health  care needs support services program and the early intervention  program,  under  which  an  eligible child may have coverage.   11.  (a)  An  approved  organization shall submit required reports and information to the commissioner in such form  and  at  times,  at  least annually,  as  may  be  required  by  the  commissioner and specified in contracts and official department of health administrative guidance,  in order  to evaluate the operations and results of the program and quality of  care  being  provided  by  such  organizations.  Such  reports   and information  shall include, but not be limited to, enrollee demographics (applicable only until the  state  enrollment  center  is  implemented), program  utilization  and  expense,  patient  care  outcomes and patient specific medical information, including encounter data maintained by  an approved  organization  for purposes of quality assurance and oversight. Any information or data collected pursuant to this  paragraph  shall  be kept  confidential  in  accordance  with Title XXI of the federal social security act or any other applicable state or federal law.  (b) In the event an approved organization fails to submit any required report  and  information,  as  specified  in  contracts   and   official department  of health administrative guidance, on or before the due date specified by the commissioner, the commissioner may reduce the  approved organization's  subsidy  payments  by  up to a total of two percent each month for a period beginning on the first  day  of  the  calendar  month following  the  original due date of the required report and information and continuing until the last day of the calendar  month  in  which  the  required  report  and  information  are  submitted; provided however, an approved organization shall not be subject to the  percentage  reduction under  the  following  conditions: (i) for any new report for which such organization  did  not  have  reasonable  notice which shall be at least sixty  days   notice   of   its   requirement,   data   and   submission specifications,   and  due  date  by  certified  mail  to  the  approved organization's chief financial officer; or (ii) for any report,  upon  a finding  by  the  commissioner  that  such report was not submitted on a timely basis for good cause, which may include, but not be  limited  to, additional time required to modify or add to computer data systems.   12.  The  commissioner shall, in consultation with the superintendent, establish procedures to coordinate the child health insurance plan  with the medical assistance program, including but not limited to, procedures to  maximize  enrollment  of  eligible  children under those programs by identification and transfer of children who are eligible or  who  become eligible  to  receive  medical  assistance  and procedures to facilitate changes in  enrollment  status  for  children  who  are  ineligible  for subsidies under this section and for children who are no longer eligible for  medical  assistance in order to facilitate and ensure continuity of coverage. The  commissioner  shall  review,  on  an  annual  basis,  the eligibility  verification  and  recertification  procedures  of approved organizations under this title to insure the appropriate  enrollment  of children.  Such review shall include, but not be limited to, an audit of a statistically representative sample of cases from among  all  approved organizations  and  shall  be  applicable  to any period during which an approved    organization's    responsibilities    include    determining eligibility.  In  the event such review and audit reveals cases which do not meet the  eligibility  criteria  for  coverage  set  forth  in  this section,   that   information   shall   be  forwarded  to  the  approved organization and the commissioner for appropriate action.   12-a. The commissioner shall establish procedures  to  audit  approved organizations  for  compliance  with  the  requirements  of  this title, including the  requirements  of  subdivision  twelve  of  this  section, contractual  provisions  established  thereunder  and advisory memoranda issued by the commissioner, title XXI of the federal social security act and any implementing federal regulations, and requirements set forth  in the  state  child  health  plan established pursuant to title XXI of the federal social security act. Approved organizations  shall  comply  with such  procedures  and  make available any data necessary to perform such audits. Audit procedures shall include,  but  not  be  limited  to,  the following:  (a)  standards  and procedures for a preliminary audit to be conducted on no more than an annual basis;  (b)  standards  and  procedures  for  the  submission  of  a  plan  of correction  by  an approved organization, including time periods allowed to implement such plan of correction;  (c) standards and procedures for a second  audit,  including  an  exit conference  which  provides  an approved organization the opportunity to rebut the composition of the audit sample  as  representative  prior  to recovery of subsidy payments and the imposition of penalties;  (d) standards and procedures for recovery of subsidy payments made for ineligible  children, which, notwithstanding any inconsistent provisions of this title, may include recoveries  based  on  extrapolated  findings from  a  statistically  representative  sample  of  cases which shall be actuarially based and consistent with accepted auditing standards; and  (e) standards and procedures  for  the  imposition  of  penalties  for substantial  noncompliance,  which  may  include, but not be limited to, financial penalties in addition to penalties set forth in section twelve  of this chapter and consistent with  applicable  federal  standards,  as specified in contracts, and contract termination; provided however  (f)  audit  standards  and  procedures  established  pursuant  to this section,  including  penalties,  shall  be  applicable  to   eligibility determinations  made  by  approved organizations only for periods during which an approved organization's responsibilities  include  making  such eligibility determinations.   14.  The  commissioner, in consultation with the superintendent, shall enter  into  agreements  with  one  or  more   persons,   not-for-profit corporations,  or  other  organizations,  other  than  a state employee, official or agency, for the performance of a comprehensive evaluation of the implementation and  effectiveness  of  the  child  health  insurance program.   Notwithstanding   any  inconsistent  provision  of  law,  the commissioner may allocate and distribute from funds otherwise  available for distribution for purposes of this title an amount not to exceed five hundred   thousand  dollars  for  the  costs  of  such  evaluation.  The evaluation shall include, but not be limited to:  (a) the overall effect of the child health insurance program on access to, utilization and  quality  of  primary  and  preventive  health  care services,   including,   but   not   limited  to,  patterns  of  service utilization, geographic  availability  of  service  providers,  possible reductions  in  uncompensated  care  as  a  result  of  the program, and enrollee satisfaction with program administration, services and quality;  (b) the impact of the child health insurance  program  on  the  health status  of  program  participants,  including  the comparative impact on families that have a child enrolled in the program  and  other  children that are not eligible and do not have coverage;  (c) the effect of the child health insurance program on emergency room utilization,  including  the  effectiveness  of preventing inappropriate utilization;  (d)  the  geographic  accessibility  of  the  child  health  insurance program,   including  the  availability  and  accessibility  of  service providers, premium levels and premium increases;  (e) the effect of community-based  and  statewide  outreach  education efforts;  (f)  the  results of a statistically valid sampling of cases verifying certification and recertification of eligibility  for  subsidy  payments under  this  title  including  but  not  limited  to  data on failure by approved organizations to adequately verify enrollee eligibility;  (g) any recommendations for programmatic changes to improve the  child health  insurance  program  based  on  program  evaluation  and enrollee satisfaction data; and  (h) a cost and patient  outcome  comparison  of  indemnity  plans  and managed care plans offered under this program.   A  preliminary  evaluation  shall be submitted to the governor and the legislature by April first, nineteen hundred ninety-five and  a  further evaluation  shall  be  submitted  by  January  first,  nineteen  hundred ninety-six.   14-a. The commissioner shall enter into an agreement with one or  more persons, not-for-profit corporations, or other organizations, other than a  state  employee,  official  or  agency,  for  comprehensive  research concerning the health care coverage of children in New York  state.  The organization  conducting  the research shall, at least annually, issue a report of its findings to the governor and the legislature. The research shall include, but not be limited to:  (a) a survey of the uninsured in the state;  (b) on-going comprehensive studies of the characteristics of uninsured children and their families, including demographic characteristics,  and reasons such children and families are uninsured;  (c)  the  collection  and  dissemination  of  data  and other relevant information relating to the health care coverage of children  and  their families; and  (d)  a  review  of  such factors relating to the uninsured in New York state as the commissioner,  in  consultation  with  the  superintendent, shall require.   15.  Notwithstanding any inconsistent provision of section one hundred twelve or one hundred sixty-three of the state finance law or any  other law,  at the discretion of the commissioner without a competitive bid or request for proposal process:  (a) contractual arrangements with approved  organizations  to  provide primary  and  preventive  health  care  services  coverage  for eligible children, or  with  organizations  for  purposes  of  public  education, outreach  and  recruitment  of  eligible children, in effect in nineteen hundred  ninety-three  may  be  extended  to  provide  for  primary  and preventive health care services coverage for eligible children or public education,  outreach  and  recruitment  of eligible children in nineteen hundred  ninety-four  and  nineteen  hundred   ninety-five   and   those contractual  arrangements with approved organizations to provide primary and preventive health care services coverage for  eligible  children  in effect  for  nineteen  hundred  ninety-five may be extended through June thirtieth, nineteen  hundred  ninety-six  to  provide  an  uninterrupted continuation  of services and additional time for program evaluation and may be  amended  as  may  be  necessary,  provided,  however,  that  the commissioner  shall periodically review the process of ensuring adequate participation of approved organizations under this section; and  (b) contractual arrangements with approved  organizations  to  provide primary  and  preventive  health  care  services  coverage  for eligible children, or  with  organizations  for  purposes  of  public  education, outreach  and  recruitment  of eligible children in effect in the period January first,  nineteen  hundred  ninety-six  through  June  thirtieth, nineteen  hundred  ninety-six  may  be  extended  for  public education, outreach  and  recruitment  of  eligible   children   through   December thirty-first, nineteen hundred ninety-six and to provide for primary and preventive  health  care services coverage for eligible children through such periods for which such coverage continues to  apply  prior  to  the addition  of  coverage  for inpatient health care services to provide an uninterrupted continuation of services and may  be  amended  as  may  be necessary.   * 16.  The  commissioner and the commissioner of social services shall jointly develop a simplified application form for  coverage  under  this title, the medical assistance program and the federal women, infants and children  program,  and  shall also develop appropriate verification and sampling procedures for the child health  insurance  plan  in  order  to facilitate  the  appropriate  enrollment  of  eligible children into the child health insurance plan, the medical  assistance  program,  and  the women,  infants  and children program. Nothing in this subdivision shall be construed to require that eligibility documentation requirements  for the  services  under  this  title  shall apply to the medical assistance program, nor shall this subdivision be construed to preclude eligibility for any  person  pending  the  development  of  that  application.  Such application  shall  be  available  for  use  by  local  social  services districts and approved organizations under this title by June thirtieth, nineteen hundred ninety-four.   * NB Expired July 1, 2007    16-a. The commissioner shall develop a simplified recertification form for use by approved organizations  in  renewing  coverage  for  eligible children under this title. The form shall include requests only for such information  that  is:  (i)  reasonably necessary to determine continued eligibility  for  coverage  under this title; and (ii) subject to change since the date of the household's initial application.   17. The commissioner, in  consultation  with  the  superintendent,  is authorized  to  establish and operate a child health information service which shall utilize advanced telecommunications technologies to meet the health information and support needs of children,  parents  and  medical professionals,  which  shall  include,  but not be limited to, treatment guidelines for children,  treatment  protocols,  research  articles  and standards  for the care of children from birth through eighteen years of age. Such information shall not constitute the practice of medicine,  as defined in article one hundred thirty-one of the education law.   18. Premium Assistance Program. (a) The commissioner shall establish a premium  assistance  program for the purchase of family coverage under a group health plan or health insurance coverage that includes coverage of an eligible child, as defined in subdivision four of section twenty-five hundred ten of this article, contingent upon:  (i) a determination by the commissioner that the  purchase  of  family coverage under this subdivision is cost effective relative to the amount the  state  would pay to obtain coverage under this title solely for the eligible child or children; and  (ii) the availability of federal financial participation in accordance with a waiver application submitted by the commissioner and approved  by the secretary of the department of health and human services.  (b)  The  commissioner  shall  establish and specify standards for the implementation of the premium assistance program in the  federal  waiver application, including, but not limited to, the following:  (i)  standards  for  eligibility  of  children  and  families  for and enrollment in the premium assistance program which shall include,  at  a minimum,  the  eligibility criteria set forth in subdivision two of this section; provided that:  (A) participation in  the  program  for  a  child  who  resides  in  a household  having  a  household  income  at  or  below two hundred fifty percent of the non-farm federal poverty level (as defined and updated by the United States department of health  and  human  services)  shall  be voluntary   and  an  eligible  child  may  disenroll  from  the  premium assistance program at any time and enroll in individual  coverage  under this title; and  (B)  participation  in  the  program  for  a  child  who  resides in a household having a household income between two  hundred  fifty-one  and four  hundred  percent of the non-farm federal poverty level (as defined and updated  by  the  United  States  department  of  health  and  human services)  and  meets certain eligibility criteria shall be mandatory. A child in this income group who meets the criteria for enrollment in  the premium assistance program shall not be eligible for individual coverage under this title;  (ii)  standards  for  required levels of employer contributions toward the cost of premiums for family coverage;  (iii) standards for the level of state  payment  toward  the  cost  of premiums for family coverage;  (iv)  standards  for the scope and level of benefits to be provided in the premium assistance program;  (v) standards for data collection including, but not limited to,  data regarding  the  substitution  of health insurance coverage that would be  provided  to  eligible  children  in  the  absence  of  family  coverage purchased pursuant to this subdivision; and  (vi)  any  other  standards  deemed  necessary  by the commissioner to implement the premium assistance program.  (c) The state share of the cost of the premium assistance program,  if implemented, shall be funded within amounts appropriated for the purpose of providing healthcare coverage for uninsured and underinsured children pursuant to this title.   19.  Claims  submitted  to  an  approved  organization for payment for medical care, services,  or  supplies  furnished  by  an  out-of-network health care provider must be submitted within fifteen months of the date the  medical  care,  services, or supplies were furnished to an eligible person to be valid and enforceable against the approved organization. If a claim by an out-of-network  health  care  provider  is  not  submitted within  fifteen  months  of  the date that the medical care, services or supplies were furnished and the claim  is  subsequently  denied  by  the approved  organization  for that reason, such out-of-network health care provider shall not seek payment  for  such  medical  care,  services  or supplies  from  the  enrollee. This deadline for claims submission shall not apply where the claims submission is warranted to  address  findings or  recommendations  identified in a state or federal audit except where such audit also indicates that an  inappropriate  provider  payment  was solely the fault of the out-of-network health care provider.   20.  For  approved  organizations with negotiated rates of payment for inpatient hospital services under contracts in effect  on  April  first, two  thousand  eight,  that  have  a  payment  rate methodology for such inpatient hospital  services  that  utilizes  rates  calculated  by  the department  of  health pursuant to paragraph (a) or (a-2) of subdivision one of section twenty-eight hundred seven-c of the public health law for patients under the medical  assistance  program,  such  rate  shall  not include  adjustments  pursuant  to  subdivision  thirty-three of section twenty-eight hundred seven-c of this chapter for contract periods  prior to January first, two thousand ten.   21.  The  commissioner may make any necessary amendments to a contract pursuant to this section with an approved organization,  as  defined  in subdivision  two  of  section  twenty-five hundred ten of this title, to allow such approved organization to participate as  a  qualified  health plan  in  a  state  health  benefit exchange established pursuant to the federal Patient Protection and Affordable Care Act  (P.L.  111-148),  as amended  by  the federal Health Care and Education Reconciliation Act of 2010 (P.L. 111-152).