2023 New York Laws › PBH - Public Health › Article 2 - The Department of Health › Title 7 - Ny State of Health › 268-C - Functions of the Marketplace.

§ 268-c. Functions of the Marketplace. The Marketplace shall:
1.  (a)  Perform  eligibility  determinations  for  federal  and state
insurance  affordability  programs  including  medical   assistance   in
accordance  with  section three hundred sixty-six of the social services
law, child health plus in accordance with  section  twenty-five  hundred
eleven  of  this  chapter,  the  basic health program in accordance with
section three hundred sixty-nine-gg of the social services law, the 1332
state innovation  program  in  accordance  with  section  three  hundred
sixty-nine-ii  of  the  social  services  law,  premium  tax credits and
cost-sharing reductions and qualified health plans  in  accordance  with
applicable  law and other health insurance programs as determined by the
commissioner;
(b) certify and make available  to  qualified  individuals,  qualified
health  plans,  including  dental  plans,  certified  by the Marketplace
pursuant to applicable law, provided  that  coverage  under  such  plans
shall  not  become  effective prior to certification by the Marketplace;
and
(c) certify and/or make  available  to  eligible  individuals,  health
plans  certified  by  the Marketplace pursuant to applicable law, and/or
participating  in  an  insurance  affordability  program   pursuant   to
applicable law, provided that coverage under such plans shall not become
effective  prior to certification by the Marketplace, and/or approval by
the commissioner.
2. Assign an  actuarial  value  to  each  Marketplace  certified  plan
offered   through  the  Marketplace  in  accordance  with  the  criteria
developed by the secretary pursuant to federal law or the superintendent
pursuant to the insurance  law  and/or  requirements  developed  by  the
Marketplace,  and  determine  each  health  plan's  level of coverage in
accordance with regulations issued by the secretary pursuant to  federal
law or the superintendent pursuant to the insurance law.
3. Utilize a standardized format for presenting health benefit options
in the Marketplace, including the use of the uniform outline of coverage
established  under section 2715 of the federal public health service act
or the insurance law.
4. Standardize the benefits available through the Marketplace at  each
level of coverage defined by the superintendent in the insurance law.
5.  Maintain  enrollment  periods  in  the  best interest of qualified
individuals consistent with federal and state law.
6. Implement procedures for  the  certification,  recertification  and
decertification  of  health  plans  as  qualified health plans or health
plans approved for sale by  the  department  of  financial  services  or
department  of  health and certified by the Marketplace, consistent with
guidelines developed by the secretary pursuant to section 1311(c) of the
federal act and requirements developed by the Marketplace.
7. Contract for health care coverage offered to qualified  individuals
through  the  Marketplace,  and in doing so shall seek to provide health
care coverage choices that offer  the  optimal  combination  of  choice,
value, quality, and service.
8.  Contract  for  health  care  coverage  offered to certain eligible
individuals  through  the  Marketplace,  pursuant  to  health  insurance
programs  as  determined by the commissioner, and in doing so shall seek
to  provide  health  care  coverage  choices  that  offer  the   optimal
combination of choice, value, quality, and service;
9.   Provide  the  minimum  requirements  an  insurer  shall  meet  to
participate in the  Marketplace,  in  the  best  interest  of  qualified
individuals or eligible individuals;
10. Require qualified health plans and/or other health plans certified
by  the  Marketplace  to offer those benefits determined to be essential
health benefits pursuant to state law or as required by the Marketplace.
11. Ensure that insurers offering health plans through the Marketplace
do not charge an individual enrollee a fee or penalty for termination of
coverage.
12.  Provide  for  the  operation  of a toll-free telephone hotline to
respond to requests for assistance.
13.  Maintain  an  internet  website  through  which   enrollees   and
prospective  enrollees  of  qualified  health  plans  and  health  plans
certified  by  the  Marketplace  may  obtain  standardized   comparative
information on such plans and insurance affordability programs.
14.  Make  available by electronic means a calculator to determine the
actual cost of coverage after the application of any premium tax  credit
under  section  36B  of  the Internal Revenue Code of 1986 or applicable
state law and any cost-sharing reduction  under  federal  or  applicable
state law.
15.  Operate  a  program  under which the Marketplace awards grants to
entities to serve as navigators in accordance  with  applicable  federal
law and regulations adopted thereunder, and/or a program under which the
Marketplace  awards  grants  to  entities  to  provide  community  based
enrollment assistance in accordance with requirements developed  by  the
Marketplace;  and/or a program under which the Marketplace certifies New
York  state  licensed  producers  to  provide  assistance  to   eligible
individuals and/or small employers pursuant to federal or state law.
16.  In  accordance  with  applicable  federal  and  state law, inform
individuals of eligibility requirements for the Medicaid  program  under
title  XIX  of  the social security act and the social services law, the
children's health insurance program (CHIP) under title XXI of the social
security act and this chapter, the basic health  program  under  section
three  hundred  sixty-nine-gg of the social services law, the 1332 state
innovation  program   in   accordance   with   section   three   hundred
sixty-nine-ii  of  the  social  services law, or any applicable state or
local public health insurance program and if, through screening  of  the
application  by  the  Marketplace,  the Marketplace determines that such
individuals are eligible for any such program, enroll  such  individuals
in such program.
17.  Grant  a  certification  that  an  individual  is exempt from the
requirement to maintain minimum essential coverage pursuant  to  federal
or  state  law  and  from  any  penalties  imposed  by such requirements
because:
(a)  there  is  no  affordable  health  plan  available  covering  the
individual, as defined by applicable law; or
(b) the individual meets the requirements for any other such exemption
from  the  requirement  to maintain minimum essential coverage or to pay
the penalty pursuant to applicable federal or state law.
18. Operate a small business health options program ("SHOP")  pursuant
to  section  1311  of  the federal act and applicable state law, through
which  eligible  small  employers   may   select   marketplace-certified
qualified  health  plans  offered in the small group market, and through
which eligible small employers may receive assistance in qualifying  for
small business tax credits available pursuant to federal and state law.
19. Enter into agreements as necessary with federal and state agencies
and  other  state  Marketplaces  to carry out its responsibilities under
this title, provided such agreements include adequate  protections  with
respect  to  the  confidentiality  of  any  information to be shared and
comply with all state and federal laws and regulations.
20. Perform duties required by the secretary,  the  secretary  of  the
United  States department of the treasury or the commissioner related to
determining eligibility for premium tax credits or reduced  cost-sharing
under applicable federal or state law.
21.   Meet   program  integrity  requirements  under  applicable  law,
including keeping an accurate accounting of  receipts  and  expenditures
and  providing  reports  to  the secretary regarding Marketplace related
activities in accordance with applicable law.
22.  Submit  information  provided  by  Marketplace   applicants   for
verification  as  required  by  section  1411(c)  of the federal act and
applicable state law.
23. Establish rules and regulations  that  do  not  conflict  with  or
prevent the application of regulations promulgated by the secretary.
24.  Determine eligibility, provide notices, and provide opportunities
for appeal and redetermination in accordance with  the  requirements  of
federal and state law.
25.  The  commissioner  is authorized to submit the appropriate waiver
applications to the United States secretary of health and human services
and/or the department of the treasury to waive any applicable provisions
of the Patient Protection and Affordable Care Act, Pub.  L.  111-148  as
amended,  or  successor  provisions, as provided for by 42 U.S.C. 18052,
and any other waivers necessary to achieve the purposes of high quality,
affordable coverage through NY State of Health, the official health plan
marketplace. The commissioner shall implement the  state  plans  of  any
such  waiver  in  a  manner consistent with applicable state and federal
laws, as authorized by the secretary of health and human services and/or
the secretary of the treasury pursuant to 42  U.S.C.  18052.  Copies  of
such  original  waiver  applications  and  amendments  thereto  shall be
provided to the chair of the senate finance committee, the chair of  the
assembly  ways  and  means  committee  and  the chairs of the senate and
assembly health committees simultaneously with their submission  to  the
federal government.
* 26.  Subject to federal approval if required, the use of state funds
and the availability of funds in the 1332 state innovation program  fund
established pursuant to section ninety-eight-d of the state finance law,
the  commissioner  shall  have  the  authority to establish a program to
provide subsidies for the payment of premium or cost sharing or both  to
assist  individuals  who are eligible to purchase qualified health plans
through the marketplace, or take such other  action  as  appropriate  to
reduce  or  eliminate  qualified health plan premiums or cost-sharing or
both.
* NB  Effective  upon  the  commissioner  of  health   obtaining   and
maintaining certain approvals (see chapter 57 of 2024 Pt. J § 10)