2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11-D - Essential Plan › 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 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, and (iii) as defined by the commissioner  and  subject  to
federal  approval,  certain  services and supports provided to enrollees
eligible pursuant to subparagraph one of paragraph  (g)  of  subdivision
one  of  section  three  hundred  sixty-six  of  this  article  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;
* NB Effective until December 31, 2025
* (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 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; and  (ii)  dental  and  vision  services  as  defined  by  the

commissioner,  and  (iii)  as defined by the commissioner 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;
* NB Effective January 1, 2026 until January 1, 2028
* (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) as defined by the commissioner 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;
* NB Effective January 1, 2028 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) except as provided by subparagraph (ii) of  this  paragraph,
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 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 title if such noncitizen would be ineligible for medical assistance
under title eleven of this article due to their immigration status;
(ii) subject to federal approval and the use of  state  funds,  unless
the  commissioner may use funds under subdivision seven of this section,
has 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 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 their immigration status;
(iii) subject to federal approval if required and  the  use  of  state
funds,  unless the commissioner may use funds under subdivision seven of
this section, a pregnant individual who is eligible  for  and  receiving
coverage  for health care services pursuant to this title is eligible to
continue to receive health care services pursuant to this  title  during
the  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 title;
(iv)  subject  to  federal  approval,  a  child  born to an individual
eligible for and receiving coverage for health care services pursuant to
this title who would be eligible for coverage pursuant to  subparagraphs
(2)  or  (4)  of paragraph (b) of subdivision 1 of section three hundred
and sixty-six of the social services law shall be deemed to have applied
for 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.
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) except as provided by subparagraph (ii) of  this  paragraph,
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  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 title if such noncitizen would be ineligible for medical assistance
under title eleven of this article due to their immigration status;
(ii)  subject  to  federal approval and the use of state funds, unless
the commissioner may use funds under subdivision seven of this  section,
has  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 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 their immigration status;
(iii)  subject  to  federal  approval if required and the use of state
funds, unless the commissioner may use funds under subdivision seven  of
this  section,  a  pregnant individual who is eligible for and receiving
coverage for health care services pursuant to this title is eligible  to
continue  to  receive health care services pursuant to this title during
the 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 title;
(iv) subject to federal  approval,  a  child  born  to  an  individual
eligible for and receiving coverage for health care services pursuant to
this  title who would be eligible for coverage pursuant to subparagraphs
(2) or (4) of paragraph (b) of subdivision 1 of  section  three  hundred
and sixty-six of the social services law shall be deemed to have applied
for  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.
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;
services  and supports as defined in subparagraph (iii) of paragraph (c)
of subdivision one of this section; and health care services  authorized
under subparagraphs (iii) and (iv) of paragraph (d) of subdivision three
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. There shall be  no  cost-sharing
obligations  for  services and supports as defined in subparagraph (iii)
of paragraph (c) of subdivision one of this  section;  and  health  care
services  authorized under subparagraphs (iii) and (iv) of paragraph (d)
of subdivision three of this section.
* 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.