§ 1121 — Voucher insurance program

New York § 1121

• Jurisdiction: New York
• Law ISC: Insurance
• Art. 11: Licensing of Insurers

Text

§ 1121. Voucher insurance program. (a) The superintendent, in\nconsultation with the commissioner of health, is authorized to conduct a\nprogram on a demonstration basis to the extent of funds available\ntherefor, through contractual arrangements with approved organizations,\nto assist individuals and families residing in specified urban, rural or\nsuburban areas in purchasing health care coverage through insurers,\nhealth maintenance organizations and integrated delivery systems.\n (b) The superintendent shall designate the urban, rural or suburban\nareas to be served by the voucher insurance program. The superintendent\nshall determine the overall amount of funding to be allocated for\nvouchers issued in designated urban, rural or suburban areas.\n (c) The superintendent, in consultation with the commissioner of\nhealth, shall establish guidelines for the submission of proposals by\norganizations for the purposes of administering the voucher insurance\nprogram including, but not limited to the following:\n (1) standards for enrollment of eligible persons, including mechanisms\nfor determining eligibility, and annual recertification;\n (2) standards for monitoring the performance of insurers, health\nmaintenance organizations and integrated delivery systems participating\nin the voucher program; and\n (3) such other criteria which may be deemed necessary.\n (d) A proposal submitted by an organization to administer the voucher\nprogram shall include the following:\n (1) a designation of the geographic area to be served;\n (2) an estimation of the number of persons who will be eligible for\nthe program and the estimated number of actual participants in the\nprogram in the specified geographic area;\n (3) a description of the procedures for enrollment of eligible\nindividuals and families in the voucher program;\n (4) a demonstration of the availability and accessibility of offices\nwhere individuals and families could obtain information and enroll in\nthe voucher program;\n (5) a description of the mechanisms for preventing fraudulent\nenrollment;\n (6) a description of the procedure for issuance of the voucher and for\nmonitoring individual and family enrollment in health maintenance\norganizations, integrated delivery systems and insurers participating in\nthe voucher program;\n (7) a description of the mechanisms for monitoring the performance of\nhealth maintenance organizations, integrated delivery systems and\ninsurers participating in the program;\n (8) a description of the procedures for marketing the voucher program\nand the proposed community outreach activities including the\nidentification of any subcontractor who will perform these activities;\n (9) a detailed description of the estimated expenses, including\npersonnel costs and other types of administrative expenses which will be\nincurred in the development and implementation of the voucher program;\n (10) a demonstration of the applicant's ability to meet the data\nanalysis and reporting requirements of the program;\n (11) a demonstration of the financial feasibility of the program; and\n (12) such other information as the superintendent may deem\nappropriate.\n (e) The superintendent, in consultation with the commissioner of\nhealth, shall make a determination whether to approve, disapprove or\nrecommend modification to the proposal of an applicant to administer the\nvoucher program.\n (f) An organization approved to administer the voucher program shall\nsubmit reports to the superintendent in such form and at times as may be\nrequired in order to facilitate evaluation of the operations and results\nof the voucher program.\n (g) The superintendent may approve more than one organization to\nadminister the voucher program in all or part of a geographic area.\n (h) The superintendent shall determine the amount of funds to be\nallocated to an approved organization to administer the voucher program\nwithin such funds which are available for purposes of the voucher\nprogram.\n (i) The superintendent shall review the marketing, community outreach\nactivities and recruitment efforts of an organization administering the\nvoucher program and may provide financial incentives if certain\nenrollment targets are met.\n (j) An organization approved to administer the voucher program may be\nsubject to financial penalties established by the superintendent for\nviolating the standards of the voucher program. Organizations\nadministering the program shall also be required to repay to the state\nall voucher payments issued on account of ineligible individuals or\nfamilies. An organization approved to administer the voucher program\nmay be removed by the superintendent as an approved organization and\nmust cooperate in the orderly transition of services to other approved\norganizations. The superintendent shall provide due notice and an\nopportunity for a hearing to an approved organization prior to\nimplementing this subsection.\n (k) Vouchers shall be issued by the organization administering the\nvoucher program to eligible individuals and families residing in\ndesignated urban, suburban or rural areas. Individuals and families\nshall submit such vouchers to participating insurers, integrated\ndelivery systems and health maintenance organizations for the purpose of\nobtaining insurance coverage.\n (l) The superintendent shall establish, for those individuals and\nfamilies eligible, the voucher amounts by regulation, and shall consider\nhousehold size, gross annual income, the cost of obtaining health care\ncoverage through a participating insurer, integrated delivery system or\nhealth maintenance organization and overall funding available for the\nvoucher program.\n (m) An insurer organized to write the kind of health insurance\nspecified in paragraph three of subsection (a) of section one thousand\none hundred thirteen of this article, and a corporation or health\nmaintenance organization authorized pursuant to article forty-three of\nthis chapter or a health maintenance organization or integrated delivery\nsystem certified pursuant to article forty-four of the public health law\nmay submit a proposal for participation in the voucher program to the\nsuperintendent who shall consult with the commissioner of health. Such\nproposal shall include:\n (1) a description of the standards for provider enrollment if\napplicable;\n (2) a description of the geographic area to be served, an estimate of\nthe eligible and actual enrollees in such designated area; and a\ndemonstration of the benefits to the community;\n (3) a demonstration of access to and delivery of high quality health\ncare services and, if applicable, that any network of health care\nproviders includes sufficient numbers of geographically accessible\nproviders to service program participants;\n (4) a demonstration of the manner in which primary and preventive care\nand medical treatment will be emphasized or substituted for hospital\ninpatient or emergency room services in order to provide more\nappropriate care and more cost effective use of general hospitals.\n (5) a description of the procedures for marketing the program, if\napplicable;\n (6) a description of health care provider payment methodologies;\n (7) a description of the premium in relation to the benefit package;\n (8) a description of the estimated expenses including personnel costs\nand other types of administrative expenses which will be incurred in the\nprogram;\n (9) a description of the quality assurance and utilization review\nmechanisms to be implemented;\n (10) a description of the provisions for arranging for or offering\nconversion coverage in the event of termination of coverage;\n (11) a demonstration of an ability to meet data analysis and reporting\nrequirements of the program; and\n (12) such other information as the superintendent may deem\nappropriate.\n (n) The superintendent, in consultation with the commissioner of\nhealth, shall make a determination whether to approve, disapprove or\nrecommend a modification to an insurer's, integrated delivery system's\nor health maintenance organization's proposal to participate in the\nvoucher program.\n (o) The superintendent, in consultation with the commissioner of\nhealth, shall ensure, to the extent possible, that the voucher program\nis available in designated urban, suburban or rural areas. The\nsuperintendent may approve more than one insurer, integrated delivery\nsystem or health maintenance organization to serve all or part of a\ngeographic area.\n (p) An approved insurer, integrated delivery system or health\nmaintenance organization shall submit reports to the superintendent and\nto the organization administering the voucher program in such form and\nat times as may be reasonably required in order to evaluate the\noperations and results of such program.\n (q) An approved insurer, integrated delivery system or health\nmaintenance organization may be removed from participation in the\nvoucher program provided, however, that eligible persons shall continue\nto receive coverage of services until such time as the orderly\ntransition to other approved insurers, integrated delivery systems and\nhealth maintenance organizations can be effected. The superintendent\nshall provide due notice and an opportunity for a hearing to an approved\ninsurer, integrated delivery systems or health maintenance organization\nprior to implementing this subsection.\n (r) Notwithstanding any inconsistent provision of law or regulation to\nthe contrary, benefits under the voucher program shall be considered\nsecondary to any other plan of insurance or benefit program under which\na person may have coverage.\n (s) An insurer, integrated delivery system or health maintenance\norganization may issue contracts approved by the superintendent,\nproviding coverage to voucher recipients, pursuant to the following\ncriteria:\n (1) the provisions are not misleading or confusing:\n (2) the provisions are consistent with the needs of the voucher\nprogram;\n (3) the materials describing the contract fully and clearly state the\nbenefits and limitations of such contract;\n (4) the duration of such contracts and the extent of exposure\nthereunder by insurers, article forty-three corporations, integrated\ndelivery systems or health maintenance organizations shall be determined\nby the superintendent;\n (5) the contract is a reasonable and appropriate approach to expand\nthe availability of health care coverage;\n (6) the funding for the contract is reasonably related to the benefits\nprovided and sufficient to support the contract;\n (7) any such contracts must include the preexisting condition\nprovisions permitted by section three thousand two hundred thirty-two\nand section four thousand three hundred eighteen of this chapter as\napplicable; and\n (8) notwithstanding any provisions of this chapter to the contrary,\nthe superintendent may waive, modify or suspend any provisions of this\nchapter, except as to mandatory benefits, or department regulations as\napplicable to the insurers, article forty-three corporations, integrated\ndelivery systems or health maintenance organizations which issue\ncoverage pursuant to this section, provided such waiver, modification or\nsuspension is based on the following:\n (A) any waiver, modification or suspension of provisions of this\nchapter or department regulations is essential to the operation of the\nvoucher program and to the rational development of programs to provide\nhealth care coverage or equivalent coverage mechanisms to the uninsured;\nand\n (B) any waiver, modification or suspension of provisions of this\nchapter or department regulations will not impair the ability of the\ninsurer, article forty-three corporation, integrated delivery system or\nhealth maintenance organization to satisfy its existing and anticipated\ncontracts and other obligations, including such standards as the\nsuperintendent shall prescribe concerning adequate capital and financial\nrequirements.\n (t) The contracts issued by insurers, integrated delivery systems or\nhealth maintenance organizations and approved by the superintendent\nproviding coverage to voucher recipients must provide for only the\nfollowing covered services:\n (1) Outpatient diagnostic X-ray and lab services;\n (2) Outpatient surgical services including anesthesia;\n (3) Mammography screening.\n (4) Cervical cytology screening.\n (5) Well-child care from birth.\n (6) Primary and preventive care services.\n (u) In order to be eligible to purchase coverage under the voucher\nprogram, the individual or family shall meet the following criteria:\n (1) reside or resides in a household having a gross household income\nat or below two hundred twenty-two percent of the non-farm federal\npoverty level (as defined and annually revised by the federal office of\nmanagement and budget). An applicant shall provide the necessary\ndocumentation to initially, and annually thereafter, determine\neligibility for a voucher. Such documentation shall include the latest\nannual income tax return. If no such income tax return has been filed\nor if the household income has changed since the date of the return,\nsuch documentation shall also include, but not be limited to: paycheck\nstubs; written documentation of income from all employers; or other\ndocumentation of income (earned or unearned) as determined by the\nsuperintendent, provided however, such documentation shall set forth the\nsource of such income;\n (2) is not eligible for medical assistance under title eleven of\narticle five of the social services law or for medicare pursuant to\ntitle eighteen of the federal social security act;\n (3) does not have equivalent health care coverage as defined by the\nsuperintendent. The applicant shall attest to the source and nature of\nhealth care coverage available;\n (4) is a resident of a designated urban, suburban or rural area in New\nYork state. Such residency shall be demonstrated by adequate proof of a\nNew York state street address or if the individual or family has no\nstreet address, then by other such proof;\n (5) has not had equivalent health care coverage within the twelve\nmonth period prior to application for a voucher. This limitation shall\nnot apply to persons who became ineligible for medical assistance or\nwhose insurance terminated as a result of loss of employment within such\nperiod;\n (6) the individual or family shall notify the organization\nadministering the voucher program within sixty days, of any changes in\nincome, health care coverage or residency that may make them ineligible\nfor the voucher program; and\n (7) any individual or family who, with the intent to obtain benefits,\nwillfully misstates income or residence or other health care coverage to\nestablish eligibility or willfully fails to notify an organization\nadministering the voucher program of an increase in income or change in\nresidence or health care coverage which may disqualify the individual or\nfamily for benefits shall repay such subsidy. Individuals seeking to\nenroll in the voucher program shall be informed that such willfull\nmisstatement or failure to notify shall result in such liability.\n (v) Nothing in this section shall be construed to provide a right or\nentitlement to insurance coverage, or a cause of action or right of\naction to eligible individuals and families, approved organizations, or\nproviders of health care services for the provision of or payment for\nsuch services relating to the availability or implementation of\ninsurance coverage under this section.\n (w) The superintendent shall implement such requirements or procedures\nas necessary to prevent, detect and deter fraud and abuse in the voucher\ninsurance program.\n