NY Soc Serv L § 369-GG (2021)
2021 New York Laws SOS - Social Services Article 5 - Assistance and Care Title 11-D - Basic Health Program 369-GG - Basic Health Program.

§  369-gg.  Basic health program. 1. Definitions. For purposes of this section:  (a) "Eligible organization" means  an  insurer  licensed  pursuant  to article  thirty-two  or forty-two of the insurance law, a corporation or an organization under article forty-three of the insurance  law,  or  an organization  certified  under  article  forty-four of the public health law, including providers  certified  under  section  forty-four  hundred three-e of the public health law;  (b) "Approved organization" means an eligible organization approved by the commissioner to underwrite a basic health insurance plan pursuant to this title;   * (c)  "Health  care  services" means (i) the services and supplies as defined by the commissioner in consultation with the  superintendent  of financial  services,  and  shall  be  consistent with and subject to the essential health benefits as defined by the commissioner  in  accordance with  the  provisions  of the patient protection and affordable care act (P.L.  111-148)  and  consistent  with  the  benefits  provided  by  the reference plan selected by the commissioner for the purposes of defining such  benefits,  and  (ii)  dental and vision services as defined by the commissioner;   * NB Repealed if federal approval is withdrawn or 42 U.S.C.  18051  is repealed   * (c)  "Health  care  services"  means  the  services  and supplies as defined by the commissioner in consultation with the  superintendent  of financial  services,  and  shall  be  consistent with and subject to the essential health benefits as defined by the commissioner  in  accordance with  the  provisions  of the patient protection and affordable care act (P.L.   111-148) and  consistent  with  the  benefits  provided  by  the reference plan selected by the commissioner for the purposes of defining such benefits;   * NB  Effective if federal approval is withdrawn or 42 U.S.C. 18051 is repealed  (d) "Qualified health  plan"  means  a  health  plan  that  meets  the criteria  for  certification  described  in  §  1311(c)  of  the Patient Protection and Affordable Care Act (P.L. 111-148),  and  is  offered  to individuals through the health insurance exchange marketplace; and   * (e)  "Basic  health  insurance  plan"  means  a standard health plan providing health care services, separate and apart from qualified health plans, that is issued by  an  approved  organization  and  certified  in accordance with this section.   * NB  Repealed  if federal approval is withdrawn or 42 U.S.C. 18051 is repealed   * (e) "Basic health insurance plan"  means  a  standard  health  plan, separate  and  apart  from  qualified health plans, that is issued by an approved organization and certified in accordance with this section.   * NB Effective if federal approval is withdrawn or 42 U.S.C. 18051  is repealed   2.  Authorization.  If it is in the financial interest of the state to do so, the commissioner of health is authorized, with  the  approval  of the  director  of  the  budget, to establish a basic health program. The commissioner's authority pursuant to this  section  is  contingent  upon obtaining  and maintaining all necessary approvals from the secretary of health and human services to offer a basic health program in  accordance with  42  U.S.C.  18051.  The  commissioner may take any and all actions necessary to  obtain  such  approvals.  Notwithstanding  the  foregoing, within  ninety  days of the effective date of the chapter of the laws of two thousand fifteen which amended  this  subdivision  the  commissioner shall  submit  a report to the temporary president of the senate and the  speaker of the assembly  detailing  a  contingency  plan  in  the  event eligibility  rules  or  regulations  are modified or repealed; or in the event federal payment is reduced from ninety five percent of the premium tax   credits  and  cost-sharing  reductions  pursuant  to  the  patient protection and affordable care act (P.L. 111-148). The contingency  plan shall  be  implemented  within ninety days of the above stated events or the time period specified in federal law.   3. Eligibility. A person is eligible to receive  coverage  for  health care services pursuant to this title if he or she:  (a) resides in New York state and is under sixty-five years of age;  (b)  is not eligible for medical assistance under title eleven of this article or for the child health insurance plan described in title  one-A of article twenty-five of the public health law;  (c)  is  not  eligible  for  minimum essential coverage, as defined in section 5000A(f) of the Internal Revenue Service Code  of  1986,  or  is eligible  for  an  employer-sponsored  plan  that  is not affordable, in accordance with section 5000A of such code; and   * (d) (i) has household income at or below two hundred percent of  the federal  poverty  line defined and annually revised by the United States department of health and human services for  a  household  of  the  same size;   and   (ii)   has  household  income  that  exceeds  one  hundred thirty-three percent of the federal poverty line  defined  and  annually revised by the United States department of health and human services for a  household  of  the  same size; however, MAGI eligible aliens lawfully present in the United States with household  incomes  at  or  below  one hundred  thirty-three  percent  of  the  federal  poverty  line shall be eligible to receive coverage for health care services  pursuant  to  the provisions  of  this title if such alien would be ineligible for medical assistance under title  eleven  of  this  article  due  to  his  or  her immigration status.   An  applicant who fails to make an applicable premium payment, if any, shall lose eligibility to receive coverage for health care  services  in accordance   with   time   frames   and  procedures  determined  by  the commissioner.   * NB Repealed if federal approval is withdrawn or 42 U.S.C.  18051  is repealed   * (d)  (i) has household income at or below two hundred percent of the federal poverty line defined and annually revised by the  United  States department  of  health  and  human  services for a household of the same size;  and  (ii)  has  household  income  that   exceeds   one   hundred thirty-three  percent  of  the federal poverty line defined and annually revised by the United States department of health and human services for a household of the same size; however,  MAGI  eligible  aliens  lawfully present  in  the  United  States  with household incomes at or below one hundred thirty-three percent  of  the  federal  poverty  line  shall  be eligible  to  receive  coverage for health care services pursuant to the provisions of this title if such alien would be ineligible  for  medical assistance  under  title  eleven  of  this  article  due  to  his or her immigration status.   An applicant who fails to make an  applicable  premium  payment  shall lose  eligibility  to  receive  coverage  for  health  care  services in accordance  with  time  frames  and   procedures   determined   by   the commissioner.   * NB  Effective if federal approval is withdrawn or 42 U.S.C. 18051 is repealed   4. Enrollment. (a) Subject to federal approval,  the  commissioner  is authorized  to  establish  an  application  and enrollment procedure for  prospective enrollees.  Such  procedure  shall  include  a  verification system for applicants, which shall be consistent with 42 USC § 1320b-7.  (b) Such procedure shall allow for continuous enrollment for enrollees to the basic health program where an individual may apply and enroll for coverage at any point.  (c)  Upon  an applicant's enrollment in a basic health insurance plan, coverage for health care services pursuant to  the  provisions  of  this title  shall be prospective. Coverage shall begin in a manner consistent with the requirements for qualified health  plans  offered  through  the health   insurance   exchange  marketplace,  as  delineated  in  federal regulation at 42 CFR 155.420(b)(1) or any successor regulation thereof.  (d) A person who has enrolled for coverage pursuant to this title, and who loses eligibility to enroll in the basic health program for a reason other than citizenship status,  lack  of  state  residence,  failure  to provide a valid social security number, providing inaccurate information that  would  affect  eligibility  when  requesting  or  renewing  health coverage pursuant to this  title,  or  failure  to  make  an  applicable premium  payment,  before  the end of a twelve month period beginning on the effective date of the person's initial eligibility for coverage,  or before  the  end  of  a twelve month period beginning on the date of any subsequent  determination  of  eligibility,  shall  have  his   or   her eligibility  for  coverage  continued until the end of such twelve month period, provided that the state  receives  federal  approval  for  using funds  from  the  basic  health  program  trust  fund, established under section 97-oooo of the state finance law, for the costs associated  with such assistance.   * 5.  Premiums  and cost sharing. (a) Subject to federal approval, the commissioner shall establish premium payments  enrollees  shall  pay  to approved  organizations for coverage of health care services pursuant to this title. No payment is required  for  individuals  with  a  household income  at  or  below  two  hundred  percent of the federal poverty line defined and annually revised by the United States department  of  health and human services for a household of the same size.  (b)  The  commissioner  shall  establish  cost sharing obligations for enrollees, subject to federal approval. There shall be  no  cost-sharing obligations  for  enrollees for dental and vision services as defined in subparagraph (ii) of paragraph (c) of subdivision one of this section.   * NB Repealed if federal approval is withdrawn or 42 U.S.C.  18051  is repealed   * 5.  Premiums  and cost sharing. (a) Subject to federal approval, the commissioner shall establish premium payments  enrollees  shall  pay  to approved  organizations for coverage of health care services pursuant to this title. Such premium payments shall be established in the  following manner:  (i)  up  to  twenty dollars monthly for an individual with a household income above one hundred and fifty percent of the federal  poverty  line but  at or below two hundred percent of the federal poverty line defined and annually revised by the United States department of health and human services for a household of the same size; and  (ii) no payment is required for individuals with a household income at or below one hundred and fifty  percent  of  the  federal  poverty  line defined  and  annually revised by the United States department of health and human services for a household of the same size.  (b) The commissioner shall  establish  cost  sharing  obligations  for enrollees, subject to federal approval.   * NB  Effective if federal approval is withdrawn or 42 U.S.C. 18051 is repealed    6. Rates of payment. (a) The commissioner shall  select  the  contract with   an   independent  actuary  to  study  and  recommend  appropriate reimbursement methodologies for the cost of health care service coverage pursuant to this title. Such independent actuary shall review  and  make recommendations concerning appropriate actuarial assumptions relevant to the  establishment  of  reimbursement  methodologies,  including but not limited to; the  adequacy  of  rates  of  payment  in  relation  to  the population  to be served adjusted for case mix, the scope of health care services approved organizations must provide, the  utilization  of  such services and the network of providers required to meet state standards.  (b)  Upon  consultation  with  the  independent  actuary  and entities representing approved  organizations,  the  commissioner  shall  develop reimbursement  methodologies  and fee schedules for determining rates of payment, which rate shall be approved by the director of the division of the budget, to be made by the department to approved  organizations  for the  cost  of health care services coverage pursuant to this title. Such reimbursement methodologies and fee schedules may include provisions for capitation arrangements.  (c)  The  commissioner  shall  have  the   authority   to   promulgate regulations,  including  emergency  regulations, necessary to effectuate the provisions of this subdivision.  (d) The department shall  require  the  independent  actuary  selected pursuant  to  paragraph  (a)  of  this subdivision to provide a complete actuarial report, along with all  actuarial  assumptions  made  and  all other data, materials and methodologies used in the development of rates for  the  basic  health  plan authorized under this section. Such report shall be provided annually to the temporary president of the senate  and the speaker of the assembly.   * 7.  Any  funds  transferred  by  the  secretary  of health and human services to the state pursuant to 42 U.S.C. 18051(d) shall be  deposited in  trust.    Funds  from  the  trust shall be used for providing health benefits through an approved organization, which, at  a  minimum,  shall include  essential  health benefits as defined in 42 U.S.C. 18022(b); to reduce the premiums, if any, and cost sharing  of  participants  in  the basic  health  program;  or for such other purposes as may be allowed by the secretary of health and human services.  Health  benefits  available through  the  basic  health  program  shall  be  provided by one or more approved organizations pursuant to an agreement with the  department  of health  and  shall meet the requirements of applicable federal and state laws and regulations.   * NB Repealed if federal approval is withdrawn or 42 U.S.C.  18051  is repealed   * 7.  Any  funds  transferred  by  the  secretary  of health and human services to the state pursuant to 42 U.S.C. 18051(d) shall be  deposited in  trust.    Funds  from  the  trust shall be used for providing health benefits through an approved organization, which, at  a  minimum,  shall include  essential  health benefits as defined in 42 U.S.C. 18022(b); to reduce the premiums and cost sharing of participants in the basic health program; or for such other purposes as may be allowed by  the  secretary of  health  and  human  services.  Health benefits available through the basic  health  program  shall  be  provided  by  one  or  more  approved organizations pursuant to an agreement with the department of health and shall  meet  the  requirements  of applicable federal and state laws and regulations.   * NB Effective if federal approval is withdrawn or 42 U.S.C. 18051  is repealed   8.  An  individual  who  is lawfully admitted for permanent residence, permanently residing in the United States under color of law, or who  is  a  non-citizen  in  a  valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15), and who would be ineligible for  medical  assistance  under title eleven of this article due to his or her immigration status if the provisions  of  section  one  hundred  twenty-two  of  this chapter were applied, shall be considered to be ineligible for medical assistance for purposes of paragraphs (b) and (c) of subdivision three of this section.   9. Reporting. The commissioner shall submit a report to the  temporary president  of  the  senate  and  the speaker of the assembly annually by December thirty-first. The  report  shall  include,  at  a  minimum,  an analysis  of  the  basic  health program and its impact on the financial interest of the  state;  its  impact  on  the  health  benefit  exchange including enrollment and premiums; its impact on the number of uninsured individuals in the state; its impact on the Medicaid global cap; and the demographics  of  basic  health  program  enrollees  including  age  and immigration status.