2023 New York Laws › PBH - Public Health › Article 2 - The Department of Health › Title 7 - Ny State of Health › 268-D - Special Functions of the Marketplace Related to Health Plan Certification and Qualified Health Plan Oversight.

§  268-d.  Special functions of the Marketplace related to health plan
certification and qualified  health  plan  oversight.  1.  Health  plans
certified by the Marketplace shall meet the following requirements:
(a) The insurer offering the health plan:
(i) is licensed or certified by the superintendent or commissioner, in
good  standing  to  offer  health  insurance coverage in this state, and
meets the requirements established by the Marketplace;
(ii) offers at  least  one  qualified  health  plan  and/or  other  or
additional  health  plans  authorized  for  sale  by  the  department of
financial services or the department in each  of  the  silver  and  gold
levels as required by state law, provided, however, that the Marketplace
may  require  additional  benefit  levels  to be offered by all insurers
participating in the Marketplace;
(iii) has filed with and received approval from the superintendent  of
its premium rates and policy or contract forms pursuant to the insurance
law and/or this chapter;
(iv)   does   not  charge  any  cancellation  fees  or  penalties  for
termination of coverage in violation of applicable law; and
(v) complies with the regulations developed  by  the  secretary  under
section  1311(c)  of  the federal act and such other requirements as the
Marketplace may establish.
(b) The health  plan:  (i)  provides  the  essential  health  benefits
package  described  in  state  law  or  required  by the Marketplace and
includes such additional benefits as are mandated by state  law,  except
that the health plan shall not be required to provide essential benefits
that duplicate the minimum benefits of qualified dental plans if:
(A)  the Marketplace has determined that at least one qualified dental
plan or dental plan approved by the department of financial services  or
the  department  is  available to supplement the health plan's coverage;
and
(B) the insurer makes prominent disclosure at the time it  offers  the
health  plan,  in a form approved by the Marketplace, that the plan does
not provide the full range of essential  pediatric  benefits,  and  that
qualified  dental  plans  or  dental plans approved by the department of
financial services or department of health providing those benefits  and
other  dental  benefits  not covered by the plan are offered through the
Marketplace;
(ii) provides at least a bronze level of coverage as defined by  state
law,  unless  the plan is certified as a qualified catastrophic plan, as
defined in section 1302(e) of the federal act and the insurance law, and
shall only be offered to individuals eligible for catastrophic coverage;
(iii) has cost-sharing requirements, including deductibles,  which  do
not  exceed  the limits established under section 1302(c) of the federal
act, state law and any requirements of the Marketplace;
(iv) complies with regulations promulgated by the  secretary  pursuant
to  section  1311(c)  of the federal act and applicable state law, which
include minimum standards in the areas of marketing  practices,  network
adequacy,   essential   community   providers   in   underserved  areas,
accreditation,  quality  improvement,  uniform  enrollment   forms   and
descriptions  of coverage and information on quality measures for health
benefit plan performance;
* (v) meets standards specified and  determined  by  the  Marketplace,
provided  that  the  standards  do  not  conflict  with  or  prevent the
application of federal requirements;
* NB Effective until January 1, 2028
* (v) meets standards specified and  determined  by  the  Marketplace,
provided  that  the  standards  do  not  conflict  with  or  prevent the
application of federal requirements; and
* NB Effective January 1, 2028
* (vi)  contracts with any national cancer institute-designated cancer
center licensed by the department within the health plan's service  area
that is willing to agree to provide cancer-related inpatient, outpatient
and  medical services to enrollees in all health plans offering coverage
through the Marketplace in such cancer center's service area  under  the
prevailing  terms and conditions that the plan requires of other similar
providers to be included in the plan's provider 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
* NB Effective until January 1, 2028
* (vi)  complies  with the insurance law and this chapter requirements
applicable to health insurance issued in this state and any  regulations
promulgated  pursuant  thereto  that do not conflict with or prevent the
application of federal requirements; and
* NB Effective January 1, 2028
* (vii) complies with the insurance law and this chapter  requirements
applicable  to health insurance issued in this state and any regulations
promulgated pursuant thereto that do not conflict with  or  prevent  the
application of federal requirements; and
* NB Repealed January 1, 2028
(c)  The  Marketplace determines that making the health plan available
through the Marketplace is in the interest of qualified  individuals  in
this state.
2. The Marketplace shall not exclude a health plan:
(a) on the basis that the health plan is a fee-for-service plan;
(b)   through   the  imposition  of  premium  price  controls  by  the
Marketplace; or
(c) on the basis that the health plan provides treatments necessary to
prevent patients' deaths in circumstances the Marketplace determines are
inappropriate or too costly.
3. The Marketplace shall require each  insurer  certified  or  seeking
certification  of  a  health  plan  as  a  qualified health plan or plan
approved for sale  by  the  department  of  financial  services  or  the
department to:
(a)  submit  a  justification  for  any  premium  increase pursuant to
applicable law prior to implementation of  such  increase.  The  insurer
shall  prominently  post  the  information on its internet website. Such
rate  increases  shall  be  subject  to  the  prior  approval   of   the
superintendent pursuant to the insurance law;
(b)(i) make available to the public and submit to the Marketplace, the
secretary and the superintendent, accurate and timely disclosure of:
(A) claims payment policies and practices;
(B) periodic financial disclosures;
(C) data on enrollment and disenrollment;
(D) data on the number of claims that are denied;
(E) data on rating practices;
(F)  information  on  cost-sharing  and  payments  with respect to any
out-of-network coverage;
(G) information on enrollee and participant rights under  title  I  of
the federal act; and
(H)  other  information  as determined appropriate by the secretary or
otherwise required by the Marketplace;
(ii) the information shall be provided in plain language, as that term
is defined in section 1311(e)(3)(B) of the federal act  and  state  law,
and  in  guidance  jointly  issued  thereunder  by the secretary and the
federal secretary of labor; and
(c) provide to individuals, in a timely manner upon the request of the
individual,  the  amount   of   cost-sharing,   including   deductibles,
copayments,  and  coinsurance,  under  the  individual's  health plan or
coverage that the  individual  would  be  responsible  for  paying  with
respect   to  the  furnishing  of  a  specific  item  or  service  by  a
participating provider. At a minimum, this  information  shall  be  made
available  to  the  individual  through  an internet website and through
other means for individuals without access to the internet.
4. The Marketplace shall not exempt any insurer seeking  certification
of  a  health  plan, regardless of the type or size of the insurer, from
licensing or solvency requirements  under  the  insurance  law  or  this
chapter,  and  shall apply the criteria of this section in a manner that
ensures  a  level  playing  field  for  insurers  participating  in  the
Marketplace.
5.  (a)  The provisions of this article that apply to qualified health
plans and plans  approved  for  sale  by  the  department  of  financial
services  and  the department also shall apply to the extent relevant to
qualified dental plans approved for sale by the department of  financial
services  or  the  department, except as modified in accordance with the
provisions of paragraphs (b) and (c) of this  subdivision  or  otherwise
required by the Marketplace.
(b)  The qualified dental plan or dental plan approved for sale by the
department of financial services and/or the department shall be  limited
to  dental  and  oral health benefits, without substantially duplicating
the benefits typically offered by health benefit  plans  without  dental
coverage,  and  shall  include,  at  a  minimum, the essential pediatric
dental  benefits  prescribed  by  the  secretary  pursuant  to   section
1302(b)(1)(J)  of the federal act, and such other dental benefits as the
Marketplace or secretary may specify in regulations.
(c) Insurers may  jointly  offer  a  comprehensive  plan  through  the
Marketplace  in  which an insurer provides the dental benefits through a
qualified dental plan or plan approved by the  department  of  financial
services  or  the  department and an insurer provides the other benefits
through a qualified health plan, provided  that  the  plans  are  priced
separately  and  also  are made available for purchase separately at the
same price.