2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11-D - Essential Plan › 369-II - 1332 State Innovation Program.

* §   369-ii.   1332   state  innovation  program.  1.  Authorization.
Notwithstanding section  three  hundred  sixty-nine-gg  of  this  title,
subject  to  federal approval, 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 1332 state
innovation program pursuant to section 1332 of  the  patient  protection
and  affordable  care  act (P.L. 111-148) and subdivision twenty-five of
section  two  hundred  sixty-eight-c  of  the  public  health  law.  The
commissioner   of   health's  authority  pursuant  to  this  section  is
contingent upon obtaining and maintaining all necessary  approvals  from
the  secretary  of  health  and  human services and the secretary of the
treasury based on an application for a waiver for state innovation.  The
commissioner  of  health  may  take all actions necessary to obtain such
approvals.
2. Definitions. For the 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 of health to underwrite a 1332 state innovation health
insurance plan pursuant to this section.
(c) "Health care services" means:
(i) the services and supplies as defined by the commissioner of health
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  of  health for the purposes of defining such benefits, and
shall include coverage of and access to the  services  of  any  national
cancer  institute-designated cancer center licensed by the department of
health within the service area of  the  approved  organization  that  is
willing  to  agree  to  provide cancer-related inpatient, outpatient and
medical services to all enrollees in approved  organizations'  plans  in
such  cancer  center's  service  area  under  the  prevailing  terms and
conditions that the approved  organization  requires  of  other  similar
providers  to  be  included  in  the  approved  organization's  network,
provided that such terms shall include reimbursement of such  center  at
no  less  than the fee-for-service medicaid payment rate and methodology
applicable to the center's inpatient and outpatient services;
(ii) dental and vision services as  defined  by  the  commissioner  of
health, and
(iii)  as defined by the commissioner of health and subject to federal
approval, certain services and supports provided to enrollees  who  have
functional  limitations  and/or  chronic illnesses that have the primary
purpose of supporting the ability of the enrollee to live or work in the
setting of their choice, which may  include  the  individual's  home,  a
worksite, or a provider-owned or controlled residential setting.
(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  NY  State  of  Health,  the  official  health
Marketplace,  or  Marketplace,  as defined in subdivision two of section
two hundred sixty-eight-a of the public health law.
(e) "Basic health insurance plan" means a 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
section three hundred sixty-nine-gg of this title.
(f)  "1332  state  innovation  plan"  means  a  standard  health  plan
providing health care services, separate  and  apart  from  a  qualified
health  plan  and  a  basic  health insurance plan, that is issued by an
approved organization and certified in accordance with this section.
3. State innovation plan eligible individual. (a) A person is eligible
to receive coverage for health care under this section if they:
(i) reside in New York state and are under sixty-five years of age;
(ii) are 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;
(iii) are 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(f) of such code; and
(iv)  have  household  income at or below two hundred 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;  and  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  noncitizens
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  section if such noncitizen would be ineligible for
medical assistance under title eleven  of  this  article  due  to  their
immigration status.
(b)  Subject  to  federal  approval,  a  child  born  to an individual
eligible for and receiving coverage for health care services pursuant to
this section who but for their eligibility under this section  would  be
eligible for coverage pursuant to subparagraphs two or four of paragraph
(b)  of  subdivision  one  of  section  three  hundred sixty-six of this
article,  shall  be  administratively  enrolled,  as  defined   by   the
commissioner  of  health,  in  medical assistance and to have been found
eligible for such assistance on the date of such  birth  and  to  remain
eligible for such assistance for a period of one year.
(c) Subject to federal approval, an individual who is eligible for and
receiving  coverage for health care services pursuant to this section is
eligible to continue to receive health care services  pursuant  to  this
section  during  the individual's pregnancy and for a period of one year
following the end of the pregnancy without regard to any change  in  the
income  of  the household that includes the pregnant individual, even if
such change would render the pregnant individual ineligible  to  receive
health care services pursuant to this section.
(d)  For  the  purposes of this section, 1332 state innovation program
eligible individuals are prohibited  from  being  treated  as  qualified
individuals  under  section  1312  of  the  Affordable  Care  Act and as
eligible individuals under section 1331 of  the  ACA  and  enrolling  in
qualified  health  plan  through the Marketplace or standard health plan
through the Basic Health Program.
4. Enrollment. (a) Subject to federal approval,  the  commissioner  of
health   is  authorized  to  establish  an  application  and  enrollment
procedure for prospective  enrollees.  Such  procedure  will  include  a

verification system for applicants, which must be consistent with 42 USC
§ 1320b-7.
(b) Such procedure shall allow for continuous enrollment for enrollees
to  the  1332 state innovation program where an individual may apply and
enroll for coverage at any point.
(c) Upon an applicant's enrollment in a 1332  state  innovation  plan,
coverage  for  health  care  services pursuant to the provisions of this
section shall be retroactive to the first day of the month in which  the
individual  was  determined  eligible,  except  in  the  case of program
transitions within the Marketplace.
(d) A person who has enrolled for coverage pursuant to  this  section,
and who loses eligibility to enroll in the 1332 state innovation 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  section,  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  their
eligibility  for  coverage  continued until the end of such twelve month
period, provided that the state  receives  federal  approval  for  using
funds under an approved 1332 waiver.
5.  Premiums.  Subject to federal approval, the commissioner of health
shall establish premium payments enrollees in a  1332  state  innovation
plan  shall  pay  to  approved organizations for coverage of health care
services pursuant to  this  section.  Such  premium  payments  shall  be
established in the following manner:
(a)  up  to fifteen dollars monthly for an individual with a household
income above two hundred percent of the federal poverty line but  at  or
below  two hundred 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; and
(b)  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.
6.  Cost-sharing.  The  commissioner   of   health   shall   establish
cost-sharing  obligations  for  enrollees,  subject to federal approval,
including childbirth  and  newborn  care  consistent  with  the  medical
assistance program under title eleven of this article. There shall be no
cost-sharing obligations for enrollees for:
(a)  dental  and  vision  services  as defined in subparagraph (ii) of
paragraph (c) of subdivision two of this section; and
(b)  services  and  supports  as  defined  in  subparagraph  (iii)  of
paragraph (c) of subdivision two of this section.
7.  Rates  of payment. (a) The commissioner of health 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 section. 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  of  health  shall

develop  reimbursement  methodologies  and fee schedules for determining
rates of payment, which rates 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 section. Such reimbursement methodologies  and  fee  schedules  may
include provisions for capitation arrangements.
(c)  The commissioner of health shall have the authority to promulgate
regulations, including emergency regulations,  necessary  to  effectuate
the provisions of this subdivision.
(d)  The  department  of  health 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 1332 state innovation plan authorized under this  section.
Such report shall be provided annually to the temporary president of the
senate and the speaker of the assembly.
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 their 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 of health 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 1332 state innovation program and its impact
on the financial interest of the state; its impact  on  the  Marketplace
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  the  1332 state innovation program enrollees including
age and immigration status.
10. Severability. If the secretary of health and human services or the
secretary  of  the  treasury  do  not  approve  any  provision  of   the
application for a state innovation waiver, such decision shall in no way
affect  or  impair any other provisions that the secretaries may approve
under this section.
* NB  Effective  upon  the  commissioner  of  health   obtaining   and
maintaining  all  necessary  approvals  from the secretary of health and
human services and the secretary of the treasury (see chapter 57 of 2023
Part H § 7)