§ 2511 — Child health insurance plan 1

New York § 2511

• Jurisdiction: New York
• Law PBH: Public Health
• Title 1-A: Child Health Insurance Plan
• Art. 25: Maternal and Child Health

Text

§ 2511. Child health insurance plan 1. (a) The commissioner, in\nconsultation with the superintendent, shall establish a program to the\nextent of funds available therefor through contractual arrangements with\napproved organizations to provide covered health care services coverage\nfor eligible children. The availability of coverage for primary and\npreventive health care services and inpatient health care services\ncoverage shall be continued pending approval of contractual arrangements\nthat include covered health care services coverage and implementation of\nsuch coverage to the extent of funds available therefor.\n (b) Coverage for covered health care services shall not be effective\nuntil such time as contractual arrangements are executed pursuant to\nthis section for such purposes and an eligible child is enrolled in the\nprogram.\n 2. In order to be eligible for a subsidy payment pursuant to\nsubdivision three of this section, a child shall meet the following\ncriteria:\n (a) (i) effective January first, nineteen hundred ninety-nine, resides\nin a household having a net household income at or below one hundred\nninety-two percent of the non-farm federal poverty level (as defined and\nupdated by the United States department of health and human services) or\nthe gross equivalent of such net income; and\n (ii) effective July first, two thousand, resides in a household having\na gross household income at or below two hundred fifty percent of the\nnon-farm federal poverty level (as defined and updated by the United\nStates department of health and human services); and\n (iii) effective September first, two thousand eight, resides in a\nhousehold having a household income at or below four hundred percent of\nthe non-farm federal poverty level (as defined and updated by the United\nStates department of health and human services);\n (b) is not eligible for medical assistance, except that a child who\nbecomes eligible for medical assistance after becoming an eligible child\nunder this title, may be eligible for a subsidy payment pursuant to\nsubdivision three of this section as medical assistance for a period up\nto three months after becoming eligible for medical assistance; and\n (c) does not have health care coverage under insurance, as defined by\nthe commissioner, in consultation with the superintendent. The applicant\nfor insurance shall attest to the source and nature of the child's\nhealth care coverage under this paragraph, if any; and\n * (e) is a resident of New York state. Such residency shall be\ndemonstrated by adequate proof, as determined by the commissioner, of a\nNew York state street address. If the child has no street address, such\nproof may include, but not be limited to, school records or other\ndocumentation determined by the commissioner.\n * NB Effective until January 1, 2014 or a later date to be determined\nby the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)\n * (e) is a resident of New York state. Such residency shall be\nattested to by the applicant for insurance, provided however, the\ncommissioner shall require adequate proof of a New York state street\naddress in circumstances when there is an inconsistency with residency\ninformation from other data sources.\n * NB Effective January 1, 2014 or a later date to be determined by the\ncommissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)\n (f) * (i) In order to establish income eligibility under this\nsubdivision at initial application, a household shall provide such\ndocumentation specified in subparagraph (iii) of this paragraph, as\nnecessary and sufficient to determine a child's financial eligibility\nfor a subsidy payment under this title. The commissioner may verify the\naccuracy of such income information provided by the household by\nmatching it against income information contained in databases to which\nthe commissioner has access, including the state's wage reporting system\npursuant to subdivision five of section one hundred seventy-one-a of the\ntax law and by means of an income verification performed pursuant to a\ncooperative agreement with the department of taxation and finance\npursuant to subdivision four of section one hundred seventy-one-b of the\ntax law.\n * NB Effective until January 1, 2014 or a later date to be determined\nby the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)\n * (i) In order to establish income eligibility under this subdivision\nat initial application, a household shall provide the social security\nnumbers for each parent and legally responsible adult who is a member of\nthe household, subject to subparagraph (v) of this paragraph. The\ncommissioner shall determine eligibility based on income information\ncontained in databases to which the commissioner has access, including\nthe state's wage reporting system pursuant to subdivision five of\nsection one hundred seventy-one-a of the tax law and by means of an\nincome verification performed pursuant to a cooperative agreement with\nthe department of taxation and finance pursuant to subdivision four of\nsection one hundred seventy-one-b of the tax law. The commissioner shall\nrequire an attestation by the household that the income information\nobtained from electronic data sources is accurate. Such attestation\nshall include any other household income information not obtained from\nan electronic data source that is necessary to determine a child's\nfinancial eligibility for a subsidy payment under this title. If the\nattestation is reasonably compatible with information obtained from\navailable data sources, no further information or documentation is\nrequired. If the attestation is not reasonably compatible with\ninformation obtained from available data sources, documentation shall be\nrequired as specified in subparagraph (iii) of this paragraph.\n * NB Effective January 1, 2014 or a later date to be determined by the\ncommissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)\n (ii) In order to establish income eligibility under this subdivision\nat recertification, the commissioner may make a redetermination of\neligibility without requiring information from the individual if able to\ndo so based on reliable information contained in the individual's\nenrollment file or other more current information contained in databases\nto which the commissioner has access, including the state's wage\nreporting system and by means of an income verification performed\npursuant to a cooperative agreement with the department of taxation and\nfinance pursuant to subdivision four of section one hundred\nseventy-one-b of the tax law. The commissioner shall require an\nattestation by the household that the income information contained in\nthe enrollment file or obtained from electronic data sources is\naccurate. Such attestation shall include any other household income\ninformation not obtained from an electronic data source that is\nnecessary to redetermine a child's financial eligibility for a subsidy\npayment under this title. In the event that there is an inconsistency\nbetween the income information attested to by the household and any\ninformation obtained by the commissioner from other sources pursuant to\nthis subparagraph, and such inconsistency is material to the household's\neligibility for a subsidy payment under this title, the commissioner\nshall require the household to provide income documentation as specified\nin subparagraph (iii) of this paragraph.\n * (iii) Income documentation shall include, but not be limited to, one\nor more of the following for each parent and legally responsible adult\nwho is a member of the household and whose income is available to the\nchild;\n (A) current annual income tax returns;\n (B) paycheck stubs;\n (C) written documentation of income from all employers; or\n (D) written documentation of income eligibility of a child for free or\nreduced breakfast or lunch through the school meal program certified by\nthe child's school, provided that:\n (I) the commissioner may verify the accuracy of the information\nprovided in the same manner and way as provided for in subparagraph (ii)\nof this paragraph; and\n (II) such documentation may not be suitable proof of income in the\nevent of a material inconsistency in income after the commissioner has\nperformed verification pursuant to subparagraph (ii) of this paragraph;\nor\n (E) other documentation of income (earned or unearned) as determined\nby the commissioner, provided, however, such documentation shall set\nforth the source of such income.\n * NB Effective until January 1, 2014 or a later date to be determined\nby the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)\n * (iii) If the attestation of household income required by\nsubparagraphs (i) and (ii) of this paragraph is not reasonably\ncompatible with information obtained from data sources, further\ninformation, including documentation, shall be required. Income\ndocumentation shall include, but not be limited to, one or more of the\nfollowing for each parent and legally responsible adult who is a member\nof the household and whose income is available to the child;\n (A) current annual income tax returns;\n (B) paycheck stubs;\n (C) written documentation of income from all employers; or\n (D) written documentation of income eligibility of a child for free or\nreduced breakfast or lunch through the school meal program certified by\nthe child's school, provided that:\n (I) the commissioner may verify the accuracy of the information\nprovided in the same manner and way as provided for in subparagraph (ii)\nof this paragraph; and\n (II) such documentation may not be suitable proof of income in the\nevent of a material inconsistency in income after the commissioner has\nperformed verification pursuant to subparagraph (ii) of this paragraph;\nor\n (E) other documentation of income (earned or unearned) as determined\nby the commissioner, provided, however, such documentation shall set\nforth the source of such income.\n * NB Effective January 1, 2014 or a later date to be determined by the\ncommissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)\n * (iv) In the event a household does not provide income documentation\nrequired by subparagraph (iii) of this paragraph within two months of\nthe approved organization's request, the approved organization shall\ndisenroll the child at the end of such two month period. Except as\nprovided in paragraph (c) of subdivision five-a of this section,\napproved organizations shall not be obligated to repay subsidy payments\nmade by the state on behalf of children enrolled during this two month\nperiod.\n * NB Effective until January 1, 2014 or a later date to be determined\nby the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)\n * (iv) In the event a household does not provide income documentation\nrequired by subparagraph (iii) of this paragraph within two months of\nthe approved organization's or state enrollment center's request,\nwhichever is applicable, the approved organization or state enrollment\ncenter shall disenroll the child at the end of such two month period.\nExcept as provided in paragraph (c) of subdivision five-a of this\nsection, approved organizations shall not be obligated to repay subsidy\npayments made by the state on behalf of children enrolled during this\ntwo month period.\n * NB Effective January 1, 2014 or a later date to be determined by the\ncommissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)\n * (v) In the event a household chooses not to provide the social\nsecurity numbers required by subparagraph (ii) of this paragraph, such\nhousehold shall provide income documentation specified in subparagraph\n(iii) of this paragraph as a condition of the child's enrollment.\nNothing in this paragraph shall be construed as obligating a household\nto provide social security numbers of parents or legally responsible\nadults as a condition of a child's enrollment or eligibility for a\nsubsidy payment under this title.\n * NB Effective until January 1, 2014 or a later date to be determined\nby the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)\n * (v) In the event a household chooses not to provide the social\nsecurity numbers required by subparagraphs (i) and (ii) of this\nparagraph, such household shall provide income documentation specified\nin subparagraph (iii) of this paragraph as a condition of the child's\nenrollment. Nothing in this paragraph shall be construed as obligating a\nhousehold to provide social security numbers of parents or legally\nresponsible adults as a condition of a child's enrollment or eligibility\nfor a subsidy payment under this title.\n * NB Effective January 1, 2014 or a later date to be determined by the\ncommissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)\n * (vi) Any income verification response by the department of taxation\nand finance pursuant to subparagraphs (i) and (ii) of this paragraph\nshall not be a public record and shall not be released by the\ncommissioner, the department of taxation and finance or an approved\norganization except pursuant to this paragraph. Information disclosed\npursuant to this paragraph shall be limited to information necessary for\nverification. Information so disclosed shall be kept confidential by the\nparty receiving such information. Such information shall be expunged\nwithin a reasonable time to be determined by the commissioner and the\ndepartment of taxation and finance.\n * NB Effective until January 1, 2014 or a later date to be determined\nby the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)\n * (vi) Any income verification response by the department of taxation\nand finance pursuant to subparagraphs (i) and (ii) of this paragraph\nshall not be a public record and shall not be released by the\ncommissioner, the department of taxation and finance, an approved\norganization, or the state enrollment center, except pursuant to this\nparagraph. Information disclosed pursuant to this paragraph shall be\nlimited to information necessary for verification. Information so\ndisclosed shall be kept confidential by the party receiving such\ninformation. Such information shall be expunged within a reasonable time\nto be determined by the commissioner and the department of taxation and\nfinance.\n * NB Effective January 1, 2014 or a later date to be determined by the\ncommissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)\n * (g) (i) Notwithstanding any inconsistent provision of law to the\ncontrary and subject to the availability of federal financial\nparticipation under title XIX of the federal social security act, a\nchild under the age of nineteen shall be presumed to be eligible for\nsubsidy payments and temporarily enrolled for coverage under this title,\nonce during a twelve month period, beginning on the first day of the\nenrollment period following the date that an approved organization\ndetermines, on the basis of preliminary information, that a child's net\nhousehold income does not exceed the income level specified in title\neleven of article five of the social services law for children eligible\nfor medical assistance based on such child's age. The temporary\nenrollment period shall continue until the earlier of the date an\neligibility determination is made pursuant to this title or title eleven\nof article five of the social services law, or two months after the date\ntemporary enrollment begins; provided however, a temporary enrollment\nperiod may be extended in the event an eligibility determination under\nthis title or title eleven of article five of the social services law is\nnot made within such two month period through no fault of the applicant\nfor insurance for medical assistance. The commissioner shall assure that\nchildren who are enrolled pursuant to this paragraph receive the\nappropriate follow-up for a determination of eligibility for benefits\nunder this title or title eleven of article five of the social services\nlaw prior to the termination of the temporary enrollment period. The\ncommissioner shall assure that children and their families are informed\nof all available enrollment sites in accordance with subdivision nine of\nthis section.\n (ii) Effective September first two thousand seven, through March\nthirty-first, two thousand fourteen temporary enrollment pursuant to\nsubparagraph (i) of this paragraph shall be provided only to children\nwho apply for recertification of coverage under this title who appear to\nbe eligible for medical assistance under title eleven of article five of\nthe social services law.\n * NB Expires July 1, 2025\n * (h) The commissioner may, in consultation with the superintendent,\npromulgate rules and regulations necessary to prevent fraud and abuse in\neligibility determinations made by approved organizations pursuant to\nthis subdivision.\n * NB Expires July 1, 2025\n (i) Notwithstanding any inconsistent provision of law, rule or\nregulation:\n (i) A newborn child who meets the eligibility criteria set forth in\nthis subdivision or subdivision five of this section, as determined by\nan approved organization or the health insurance exchange marketplace,\nwhichever is applicable, shall be enrolled retroactively to the first\nday of the month in which the child is born, provided that the applicant\nfor insurance submits a completed and signed application and required\ninformation and documentation within sixty days of the child's birth.\n (ii) A newborn child shall be presumed eligible for subsidy payments\nunder this subdivision or eligible for coverage under subdivision five\nof this section, provided that the applicant for insurance submits a\ncompleted and signed application within sixty days of the child's birth.\nOnce eligibility is determined by the approved organization or the\nhealth insurance exchange marketplace, whichever is applicable, on the\nbasis of preliminary information, the child shall be enrolled\nretroactively to the first day of the month in which the child is born.\nAll other procedures and standards regarding presumptive enrollment\napplicable to eligible children enrolled under this title and specified\nin state contracts with approved organizations or implemented by the\nhealth insurance exchange marketplace, whichever is applicable, shall\napply to presumptive enrollment of newborn children.\n (j) Where an application for recertification of coverage under this\ntitle contains insufficient information for a final determination of\neligibility for continued coverage, a child shall be presumed eligible\nfor a period not to exceed the earlier of two months beyond the\npreceding period of eligibility or the date upon which a final\ndetermination of eligibility is made based on the submission of\nadditional data. In the event such additional information is not\nsubmitted within two months of the approved organization's or state\nenrollment center's request, whichever is applicable, the approved\norganization or state enrollment center shall disenroll the child\nfollowing the expiration of such two month period. Except as provided in\nparagraph (c) of subdivision five-a of this section, approved\norganizations shall not be obligated to repay subsidy payments received\non behalf of children enrolled during this two month period.\n 2-a. (a) An approved organization that has reasonable cause to believe\nthat an applicant for insurance, parent or legally responsible adult has\nprovided false income information may submit tax returns and any other\navailable income information, including, if not prohibited by federal\nlaw for purposes of income verification, social security account\nnumbers, to the department as may be necessary to determine income\neligibility. The department shall promptly furnish to the department of\ntaxation and finance, pursuant to the agreements authorized by\nsubdivision five of section one hundred seventy-one-a and subdivision\nfour of section one hundred seventy-one-b of the tax law, the names,\naddress and social security account numbers, if available, of the\nparents and legally responsible adults who are members of the household,\ntogether with a request that the department of taxation and finance,\npursuant to those agreements, promptly ascertain insofar as is possible,\nand from the most recent available data, whether the collective income\nreported by those individuals exceeds the income eligibility level for\nthat household, as determined by the department in compliance with\nparagraph (a) of subdivision two of this section. The department, in\nconsultation with the department of taxation and finance, shall\nestablish a methodology for comparing numerical equivalents. In\nascertaining whether a household's income exceeds the income eligibility\nthreshold transmitted by the department, the department of taxation and\nfinance shall also examine information available pursuant to section one\nhundred seventy-one-a of the tax law where any of the named individuals\nhave failed to file a New York state income tax return for the most\nrecent filing year or where there is an indication, from the department\nor otherwise, that the individual's income may have changed. Reliance on\nsuch section one hundred seventy-one-a information shall be specially\nindicated in the department of taxation and finance's response. This\nprovision shall not be construed to authorize the department of taxation\nand finance to disclose any figure on any personal income tax return.\nThe department shall promptly inform the approved organization of the\nresponse from the department of taxation and finance. Submission of\nincome information for verification shall not delay the application of\nany other provision of this section to an applicant for insurance or an\nenrolled child.\n (b) Before an approved organization submits income information to the\ndepartment for verification with the department of taxation and finance,\nit shall:\n (i) provide the applicant for insurance with notification of its\nintent to seek such verification;\n (ii) notify the applicant for insurance of the confidentiality and\nexpungement provisions contained in paragraph (c) of this subdivision;\nand\n (iii) provide the applicant for insurance with the opportunity to\nreview and modify the income information.\n (c) Such income information and verification response by the\ndepartment of taxation and finance shall not be a public record and\nshall not be released by the department, the department of taxation and\nfinance or the approved organization except pursuant to this\nsubdivision. Information disclosed pursuant to this section shall be\nlimited to information necessary for verification. Information so\ndisclosed shall be kept confidential by the party receiving such\ninformation. Such income information shall be expunged within a\nreasonable time to be determined by the department and the department of\ntaxation and finance.\n 2-b. (a) For purposes of claiming federal financial participation\nunder paragraph nine of subsection (c) of section twenty-one hundred\nfive of the federal social security act, a household shall provide:\n (i) the social security number for the applicant to be verified by the\ncommissioner in accordance with a process established by the social\nsecurity administration pursuant to federal law, or\n (ii) documentation of citizenship and identity of the applicant\nconsistent with requirements under the medical assistance program, as\nspecified by the commissioner on the initial application.\n (b) Pending receipt of the information required by subparagraph (i) of\nparagraph (a) of this subdivision, an initial application shall continue\nto be processed by an approved organization or enrollment facilitator\nand a child shall be presumptively enrolled in the program in accordance\nwith procedures and timeframes currently specified in contracts.\n 2-c. Express lane eligibility. (a) Notwithstanding any inconsistent\nprovision of law, rule or regulation, the commissioner is authorized to\n(i) establish standards and procedures for express lane enrollment and\nrenewal implemented in accordance with section 2107(e)(1)(B) of the\nfederal social security act, including but not limited to reliance on a\nfinding made by an express lane agency, as defined in section\n1902(e)(13)(F) of the federal social security act, to determine whether\na child meets one or more of the eligibility criteria set forth in\nsubdivision two of this section; (ii) specify such standards and\nprocedures in the state child health plan established under title XXI of\nthe federal social security act and applicable contracts with approved\norganizations and enrollment facilitators; and (iii) waive any\ninformation and documentation requirements set forth in this section\nnecessary to implement express lane eligibility pursuant to standards\nand procedures established under subparagraphs (i) and (ii) of this\nparagraph; provided, however, that information and documentation\nrequired pursuant to subdivision two-b of this section may not be\nwaived.\n (b) Subject to federal approval, such standards and procedures shall\nspecify that information and documentation regarding citizenship and\nimmigration status collected by an express lane agency and provided to\nthe commissioner for the purpose of express lane eligibility may be used\nto satisfy the requirements of subdivision two-b of this section.\n (c) Such standards and procedures shall also include a process for\ndetermining enrollment error rates and implementing corrective actions\nas required by section 1902(e)(13)(E) of the federal social security\nact.\n 3. Subsidy payments shall be made, pursuant to subdivision eight of\nthis section, to approved organizations for the purposes of subsidizing\nthe entire cost of coverage for eligible children meeting the criteria\nof subdivision two of this section. Notwithstanding any inconsistent\nprovision of this subdivision, the total annual aggregate cost-sharing\nwith respect to all eligible children in a family under this section\nshall not exceed amounts provided pursuant to applicable federal law. In\norder to be eligible for a subsidy payment pursuant to this subdivision\na premium payment shall be paid for an eligible child in accordance with\nthe provisions of subdivision nine of section twenty-five hundred ten of\nthis title. Nothing herein shall preclude payment of the premium on\nbehalf of an eligible child on a monthly, quarterly, semi-annual or\nannual basis.\n 4. Households shall report to the approved organization or state\nenrollment center, whichever is applicable, within thirty days, any\nchanges in New York state residency or health care coverage under\ninsurance that may make a child ineligible for subsidy payments pursuant\nto this section. Any individual who, with the intent to obtain benefits,\nwillfully misstates income or residence to establish eligibility\npursuant to subdivision two of this section or willfully fails to notify\nan approved organization or state enrollment center of a change in\nresidence or health care coverage pursuant to this subdivision shall\nrepay such subsidy to the commissioner. Individuals seeking to enroll\nchildren for coverage shall be informed that such willful misstatement\nor failure to notify shall result in such liability.\n 4-a. Any individual who, with the intent to obtain benefits, willfully\nmisstates income or residence to establish eligibility pursuant to\nsubdivision two of this section or willfully fails to notify an approved\norganization of an increase in income or change in residence pursuant to\nsubdivision two of this section shall repay such subsidy to the\ncommissioner. Individuals seeking to enroll children for coverage shall\nbe informed that such willful misstatement or failure to notify shall\nresult in such liability.\n 5. Notwithstanding any inconsistent provisions of subdivision two of\nthis section, an individual who meets the criteria of paragraphs (b) and\n(c) of subdivision two of this section but not the criteria of paragraph\n(a) of such subdivision may be enrolled for covered health care\nservices, provided however, that an approved organization shall not be\neligible to receive a subsidy payment for providing coverage to such\nindividuals. The cost of coverage shall be determined by the\ncommissioner, in consultation with the superintendent and shall be no\nmore than the cost of providing such coverage.\n 5-a. Obligations of approved organizations or the state enrollment\ncenter. (a) An approved organization or state enrollment center,\nwhichever is applicable, shall have the obligation to review all\ninformation provided pursuant to subdivision two of this section and\nshall not certify or recertify a child as eligible for a subsidy payment\nunless the child meets the eligibility criteria.\n (b) An approved organization or state enrollment center, whichever is\napplicable, shall promptly review all information relating to a\npotential change in eligibility based on information provided pursuant\nto subdivision four of this section. Within at least thirty days after\nreceipt of such information, the approved organization or state\nenrollment center shall make a determination whether the child is still\neligible for a subsidy payment and shall notify the household and the\ncommissioner if it determines the child is not eligible for a subsidy\npayment.\n (c) Any approved organization which engages in a pattern and practice\nof enrolling or recertifying children who are ineligible pursuant to\nsubdivision two of this section, as determined by the commissioner, in\nconsultation with the superintendent, shall be required to repay all\nsubsidy payments received on account of ineligible children. Improper\nenrollment based upon a good faith reliance on documentation which\nappears accurate on its face shall not constitute a pattern or practice.\nAny such approved organization may also be removed as an approved\norganization, provided however, that eligible children shall continue to\nreceive services until such time as the orderly transition to other\napproved organizations can be effected.\n 6. The commissioner shall, in consultation with the superintendent,\nestablish guidelines for the submission of proposals by eligible\norganizations for the purposes of providing covered health care services\ncoverage to eligible children including, but not limited to, the\nfollowing components:\n (a) standards for individual enrollment including mechanisms for\npresumptive eligibility and annual recertification;\n (b) standards for provider enrollment;\n (c) standards for scope of covered health care service benefits;\n (d) standards for health care provider payment methodologies, provided\nhowever, that levels and methods of payment shall be consistent with\nthose provided under similar insurance plans;\n (e) standards for appropriate utilization review, quality assurance\nand case management mechanisms; and\n (f) such other criteria which may be deemed necessary.\n 6-a. The commissioner, in consultation with the superintendent, may\nestablish a program for cards issued to eligible children which can\nstore or access information electronically, including the identity of\nthe child and such other medical data and information as the\ncommissioner, in consultation with the superintendent, may prescribe.\n 7. (a) A proposal submitted by an eligible organization shall meet the\nfollowing criteria:\n (i) designate the geographic area to be served by the program, and\nestimate the number of eligible participants and actual participants in\nsuch designated area;\n (ii) assure access to and delivery of high quality, appropriate\ncovered health care services and, when applicable, include a network of\nhealth care providers in sufficient numbers and geographically\naccessible to service program participants;\n (iii) describe the procedures for marketing and determining\neligibility for the health care coverage plan in the program location,\nincluding the designation of other entities which may perform such\nfunctions under contract with the organization;\n (iv) describe proposed health care provider payment methodologies;\n (v) describe in detail the estimated expenses, including personnel\ncosts and other types of administrative expenses which will be incurred\nin the development and implementation of the program;\n (vi) describe the quality assurance, utilization review and case\nmanagement mechanisms to be implemented;\n (vii) demonstrate the applicant's ability to meet the data analysis\nand reporting requirements of the program;\n (viii) describe the benefit package to be offered by the program and\nthe cost of such benefit package;\n (ix) describe the provisions for arranging for or offering conversion\ncoverage in the event of termination of coverage under this title;\n (x) demonstrate financial feasibility of the program;\n (xi) describe the premium, copayments and deductibles to be paid by\nprogram participants who are ineligible for subsidy payments; and\n (xii) include such other information as the commissioner and the\nsuperintendent may deem appropriate.\n (b) The commissioner, in consultation with the superintendent, shall\nmake a determination whether to approve, disapprove or recommend\nmodification of the proposal. In order for a proposal to be approved by\nthe commissioner, the proposal must also be approved by the\nsuperintendent with respect to the provisions of subparagraphs (ix) and\n(xii) of paragraph (a) of this subdivision.\n (c) The commissioner, in consultation with the superintendent, shall\nensure, to the extent possible, that child health insurance plan\ncoverage is available in all geographic areas. The commissioner may\napprove more than one approved organization to serve all or part of a\ngeographic area.\n 7-a. (a) Notwithstanding any inconsistent provisions of subdivisions\none and three of section two thousand five hundred ten of this title,\nsubdivisions six and seven of this section, subject to paragraph (b) of\nthis subdivision, and section one hundred sixty-three of the state\nfinance law, the commissioner may contract with organizations approved\nunder section three hundred sixty-four-j of the social services law,\nwithout a competitive bid or request for proposal process, to provide\ncovered health care services coverage for eligible children pursuant to\nthis title.\n (b) In order to be approved pursuant to this subdivision, an\norganization shall meet the criteria set forth in subdivision seven of\nthis section and shall comply with standards established by the\ncommissioner, in consultation with the superintendent, pursuant to\nsubdivision six of this section.\n (c) Organizations approved pursuant to this subdivision shall comply\nwith the requirements of this title and contractual provisions\nestablished thereunder, title XXI of the federal social security act and\nany implementing federal regulations, and requirements set forth in the\nstate child health plan established pursuant to title XXI of the federal\nsocial security act.\n (d) Notwithstanding any inconsistent provision of section one hundred\ntwelve or one hundred sixty-three of the state finance law, at the\ndiscretion of the commissioner, without a competitive bid or request for\nproposal process, contractual arrangements with approved organizations,\nas defined in subdivision two of section twenty-five hundred ten of this\narticle, in effect in two thousand seven may be extended to any period\non and after July first, two thousand seven to provide an uninterrupted\ncontinuation of services and may be amended as deemed necessary.\n 8. The commissioner shall determine the amount of funds to be\nallocated to an approved organization for the purposes described in\nsubdivision one of this section within such funds which may be available\nfor the purposes of this article. (a) Subsidy payments made to approved\norganizations on and after April first, two thousand five through March\nthirty-first, two thousand six, shall be at amounts approved prior to\nApril first, two thousand five. Applications for increases to subsidy\npayments submitted by approved organizations to the superintendent on or\nafter January first, two thousand five, shall not be considered for\napproval until after March thirty-first, two thousand six. (b) Further,\nsubsidy payments made to approved organizations on and after April\nfirst, two thousand seven through March thirty-first, two thousand\neight, shall be at amounts approved prior to April first, two thousand\nseven. Applications for increases to subsidy payments submitted by\napproved organizations to the superintendent on or after January first,\ntwo thousand seven, shall not be considered for approval until after\nMarch thirty-first, two thousand eight. (c) Nothing in this subdivision\nshall prohibit decreases in subsidy payments in accordance with relevant\ncontract provisions.\n (d)(i) Effective April first, two thousand nine, payment for marketing\nand facilitated enrollment activities set forth in subdivision nine of\nthis section and included in subsidy payments made to approved\norganizations providing such services pursuant to a contract with the\nstate shall be limited to an amount determined annually by the\ncommissioner.\n (ii) Such subsidy payments shall be adjusted by the commissioner to\nremove any costs of approved organizations in excess of the amount\ndetermined in accordance with subparagraph (i) of this paragraph based\non cost reports submitted to the department by approved organizations.\n (f) The commissioner shall adjust subsidy payments made to approved\norganizations on and after April first, two thousand eleven through\nMarch thirty-first, two thousand twelve, so that the amount of each such\npayment is reduced by one and seven-tenths percent.\n (g) The commissioner may increase subsidy payments made to approved\norganizations that voluntarily participate in the multi-payor patient\ncentered medical home program to reflect additional costs associated\nwith enhanced payments made to certified medical homes by approved\norganizations as required by article twenty-nine-AA of this chapter.\n (h) Notwithstanding any inconsistent provision of this title, articles\nthirty-two and forty-three of the insurance law and subsection (e) of\nsection eleven hundred twenty of the insurance law, for the period April\nfirst, two thousand fourteen through March thirty-first, two thousand\nfifteen, subsidy payments made to approved organizations shall be at\namounts approved prior to April first, two thousand fourteen.\n (i) Notwithstanding any inconsistent provision of this title, articles\nthirty-two and forty-three of the insurance law and subsection (e) of\nsection eleven hundred twenty of the insurance law:\n (i) The commissioner shall, subject to approval of the director of the\ndivision of the budget, develop reimbursement methodologies for\ndetermining the amount of subsidy payments made to approved\norganizations for the cost of covered health care services coverage\nprovided pursuant to this title for payments made on and after January\nfirst, two thousand twenty-four.\n (ii) Effective January first, two thousand twenty-three, the\ncommissioner shall coordinate with the superintendent of financial\nservices for the transition of the subsidy payment rate setting function\nto the department and, in conjunction with its independent actuary,\nreview reimbursement methodologies developed in accordance with\nsubparagraph (i) of this paragraph. Notwithstanding section one hundred\nsixty-three of the state finance law, the commissioner may select and\ncontract with the independent actuary selected pursuant to subdivision\neighteen of section three hundred sixty-four-j of the social services\nlaw, without a competitive bid or request for proposal process. Such\nindependent actuary shall review and make recommendations concerning\nappropriate actuarial assumptions relevant to the establishment of\nreimbursement methodologies, including but not limited to the adequacy\nof subsidy payment amounts in relation to the population to be served\nadjusted for case mix, the scope of services approved organizations must\nprovide, the utilization of such services and the network of providers\nrequired to meet state standards.\n 9. The commissioner shall, within amounts available therefor, contract\nwith community-based and other marketing organizations for purposes of\npublic education, outreach, and recruitment of eligible children,\nincluding the distribution of applications and information regarding\nenrollment. In awarding such contracts, the commissioner shall consider\nthe marketing, outreach and recruitment efforts of approved\norganizations, and the extent to which such organizations are able to\neffectively target efforts in geographic regions where the proportion of\neligible children enrolled under this title are lower than in other\ngeographic regions of the state. Community-based organizations shall\ninclude, but not be limited to: day care centers, schools,\ncommunity-based diagnostic and treatment centers, and hospitals.\n 10. Notwithstanding any other law or agreement to the contrary, and\nexcept in the case of a child or children who also becomes eligible for\nmedical assistance, benefits under this title shall be considered\nsecondary to any other plan of insurance or benefit program, except the\nchildren and youth with special health care needs support services\nprogram and the early intervention program, under which an eligible\nchild may have coverage.\n 11. (a) An approved organization shall submit required reports and\ninformation to the commissioner in such form and at times, at least\nannually, as may be required by the commissioner and specified in\ncontracts and official department of health administrative guidance, in\norder to evaluate the operations and results of the program and quality\nof care being provided by such organizations. Such reports and\ninformation shall include, but not be limited to, enrollee demographics\n(applicable only until the state enrollment center is implemented),\nprogram utilization and expense, patient care outcomes and patient\nspecific medical information, including encounter data maintained by an\napproved organization for purposes of quality assurance and oversight.\nAny information or data collected pursuant to this paragraph shall be\nkept confidential in accordance with Title XXI of the federal social\nsecurity act or any other applicable state or federal law.\n (b) In the event an approved organization fails to submit any required\nreport and information, as specified in contracts and official\ndepartment of health administrative guidance, on or before the due date\nspecified by the commissioner, the commissioner may reduce the approved\norganization's subsidy payments by up to a total of two percent each\nmonth for a period beginning on the first day of the calendar month\nfollowing the original due date of the required report and information\nand continuing until the last day of the calendar month in which the\nrequired report and information are submitted; provided however, an\napproved organization shall not be subject to the percentage reduction\nunder the following conditions: (i) for any new report for which such\norganization did not have reasonable notice which shall be at least\nsixty days notice of its requirement, data and submission\nspecifications, and due date by certified mail to the approved\norganization's chief financial officer; or (ii) for any report, upon a\nfinding by the commissioner that such report was not submitted on a\ntimely basis for good cause, which may include, but not be limited to,\nadditional time required to modify or add to computer data systems.\n 12. The commissioner shall, in consultation with the superintendent,\nestablish procedures to coordinate the child health insurance plan with\nthe medical assistance program, including but not limited to, procedures\nto maximize enrollment of eligible children under those programs by\nidentification and transfer of children who are eligible or who become\neligible to receive medical assistance and procedures to facilitate\nchanges in enrollment status for children who are ineligible for\nsubsidies under this section and for children who are no longer eligible\nfor medical assistance in order to facilitate and ensure continuity of\ncoverage. The commissioner shall review, on an annual basis, the\neligibility verification and recertification procedures of approved\norganizations under this title to insure the appropriate enrollment of\nchildren. Such review shall include, but not be limited to, an audit of\na statistically representative sample of cases from among all approved\norganizations and shall be applicable to any period during which an\napproved organization's responsibilities include determining\neligibility. In the event such review and audit reveals cases which do\nnot meet the eligibility criteria for coverage set forth in this\nsection, that information shall be forwarded to the approved\norganization and the commissioner for appropriate action.\n 12-a. The commissioner shall establish procedures to audit approved\norganizations for compliance with the requirements of this title,\nincluding the requirements of subdivision twelve of this section,\ncontractual provisions established thereunder and advisory memoranda\nissued by the commissioner, title XXI of the federal social security act\nand any implementing federal regulations, and requirements set forth in\nthe state child health plan established pursuant to title XXI of the\nfederal social security act. Approved organizations shall comply with\nsuch procedures and make available any data necessary to perform such\naudits. Audit procedures shall include, but not be limited to, the\nfollowing:\n (a) standards and procedures for a preliminary audit to be conducted\non no more than an annual basis;\n (b) standards and procedures for the submission of a plan of\ncorrection by an approved organization, including time periods allowed\nto implement such plan of correction;\n (c) standards and procedures for a second audit, including an exit\nconference which provides an approved organization the opportunity to\nrebut the composition of the audit sample as representative prior to\nrecovery of subsidy payments and the imposition of penalties;\n (d) standards and procedures for recovery of subsidy payments made for\nineligible children, which, notwithstanding any inconsistent provisions\nof this title, may include recoveries based on extrapolated findings\nfrom a statistically representative sample of cases which shall be\nactuarially based and consistent with accepted auditing standards; and\n (e) standards and procedures for the imposition of penalties for\nsubstantial noncompliance, which may include, but not be limited to,\nfinancial penalties in addition to penalties set forth in section twelve\nof this chapter and consistent with applicable federal standards, as\nspecified in contracts, and contract termination; provided however\n (f) audit standards and procedures established pursuant to this\nsection, including penalties, shall be applicable to eligibility\ndeterminations made by approved organizations only for periods during\nwhich an approved organization's responsibilities include making such\neligibility determinations.\n 14. The commissioner, in consultation with the superintendent, shall\nenter into agreements with one or more persons, not-for-profit\ncorporations, or other organizations, other than a state employee,\nofficial or agency, for the performance of a comprehensive evaluation of\nthe implementation and effectiveness of the child health insurance\nprogram. Notwithstanding any inconsistent provision of law, the\ncommissioner may allocate and distribute from funds otherwise available\nfor distribution for purposes of this title an amount not to exceed five\nhundred thousand dollars for the costs of such evaluation. The\nevaluation shall include, but not be limited to:\n (a) the overall effect of the child health insurance program on access\nto, utilization and quality of primary and preventive health care\nservices, including, but not limited to, patterns of service\nutilization, geographic availability of service providers, possible\nreductions in uncompensated care as a result of the program, and\nenrollee satisfaction with program administration, services and quality;\n (b) the impact of the child health insurance program on the health\nstatus of program participants, including the comparative impact on\nfamilies that have a child enrolled in the program and other children\nthat are not eligible and do not have coverage;\n (c) the effect of the child health insurance program on emergency room\nutilization, including the effectiveness of preventing inappropriate\nutilization;\n (d) the geographic accessibility of the child health insurance\nprogram, including the availability and accessibility of service\nproviders, premium levels and premium increases;\n (e) the effect of community-based and statewide outreach education\nefforts;\n (f) the results of a statistically valid sampling of cases verifying\ncertification and recertification of eligibility for subsidy payments\nunder this title including but not limited to data on failure by\napproved organizations to adequately verify enrollee eligibility;\n (g) any recommendations for programmatic changes to improve the child\nhealth insurance program based on program evaluation and enrollee\nsatisfaction data; and\n (h) a cost and patient outcome comparison of indemnity plans and\nmanaged care plans offered under this program.\n A preliminary evaluation shall be submitted to the governor and the\nlegislature by April first, nineteen hundred ninety-five and a further\nevaluation shall be submitted by January first, nineteen hundred\nninety-six.\n 14-a. The commissioner shall enter into an agreement with one or more\npersons, not-for-profit corporations, or other organizations, other than\na state employee, official or agency, for comprehensive research\nconcerning the health care coverage of children in New York state. The\norganization conducting the research shall, at least annually, issue a\nreport of its findings to the governor and the legislature. The research\nshall include, but not be limited to:\n (a) a survey of the uninsured in the state;\n (b) on-going comprehensive studies of the characteristics of uninsured\nchildren and their families, including demographic characteristics, and\nreasons such children and families are uninsured;\n (c) the collection and dissemination of data and other relevant\ninformation relating to the health care coverage of children and their\nfamilies; and\n (d) a review of such factors relating to the uninsured in New York\nstate as the commissioner, in consultation with the superintendent,\nshall require.\n 15. Notwithstanding any inconsistent provision of section one hundred\ntwelve or one hundred sixty-three of the state finance law or any other\nlaw, at the discretion of the commissioner without a competitive bid or\nrequest for proposal process:\n (a) contractual arrangements with approved organizations to provide\nprimary and preventive health care services coverage for eligible\nchildren, or with organizations for purposes of public education,\noutreach and recruitment of eligible children, in effect in nineteen\nhundred ninety-three may be extended to provide for primary and\npreventive health care services coverage for eligible children or public\neducation, outreach and recruitment of eligible children in nineteen\nhundred ninety-four and nineteen hundred ninety-five and those\ncontractual arrangements with approved organizations to provide primary\nand preventive health care services coverage for eligible children in\neffect for nineteen hundred ninety-five may be extended through June\nthirtieth, nineteen hundred ninety-six to provide an uninterrupted\ncontinuation of services and additional time for program evaluation and\nmay be amended as may be necessary, provided, however, that the\ncommissioner shall periodically review the process of ensuring adequate\nparticipation of approved organizations under this section; and\n (b) contractual arrangements with approved organizations to provide\nprimary and preventive health care services coverage for eligible\nchildren, or with organizations for purposes of public education,\noutreach and recruitment of eligible children in effect in the period\nJanuary first, nineteen hundred ninety-six through June thirtieth,\nnineteen hundred ninety-six may be extended for public education,\noutreach and recruitment of eligible children through December\nthirty-first, nineteen hundred ninety-six and to provide for primary and\npreventive health care services coverage for eligible children through\nsuch periods for which such coverage continues to apply prior to the\naddition of coverage for inpatient health care services to provide an\nuninterrupted continuation of services and may be amended as may be\nnecessary.\n * 16. The commissioner and the commissioner of social services shall\njointly develop a simplified application form for coverage under this\ntitle, the medical assistance program and the federal women, infants and\nchildren program, and shall also develop appropriate verification and\nsampling procedures for the child health insurance plan in order to\nfacilitate the appropriate enrollment of eligible children into the\nchild health insurance plan, the medical assistance program, and the\nwomen, infants and children program. Nothing in this subdivision shall\nbe construed to require that eligibility documentation requirements for\nthe services under this title shall apply to the medical assistance\nprogram, nor shall this subdivision be construed to preclude eligibility\nfor any person pending the development of that application. Such\napplication shall be available for use by local social services\ndistricts and approved organizations under this title by June thirtieth,\nnineteen hundred ninety-four.\n * NB Expired July 1, 2007\n 16-a. The commissioner shall develop a simplified recertification form\nfor use by approved organizations in renewing coverage for eligible\nchildren under this title. The form shall include requests only for such\ninformation that is: (i) reasonably necessary to determine continued\neligibility for coverage under this title; and (ii) subject to change\nsince the date of the household's initial application.\n 17. The commissioner, in consultation with the superintendent, is\nauthorized to establish and operate a child health information service\nwhich shall utilize advanced telecommunications technologies to meet the\nhealth information and support needs of children, parents and medical\nprofessionals, which shall include, but not be limited to, treatment\nguidelines for children, treatment protocols, research articles and\nstandards for the care of children from birth through eighteen years of\nage. Such information shall not constitute the practice of medicine, as\ndefined in article one hundred thirty-one of the education law.\n 18. Premium Assistance Program. (a) The commissioner shall establish a\npremium assistance program for the purchase of family coverage under a\ngroup health plan or health insurance coverage that includes coverage of\nan eligible child, as defined in subdivision four of section twenty-five\nhundred ten of this article, contingent upon:\n (i) a determination by the commissioner that the purchase of family\ncoverage under this subdivision is cost effective relative to the amount\nthe state would pay to obtain coverage under this title solely for the\neligible child or children; and\n (ii) the availability of federal financial participation in accordance\nwith a waiver application submitted by the commissioner and approved by\nthe secretary of the department of health and human services.\n (b) The commissioner shall establish and specify standards for the\nimplementation of the premium assistance program in the federal waiver\napplication, including, but not limited to, the following:\n (i) standards for eligibility of children and families for and\nenrollment in the premium assistance program which shall include, at a\nminimum, the eligibility criteria set forth in subdivision two of this\nsection; provided that:\n (A) participation in the program for a child who resides in a\nhousehold having a household income at or below two hundred fifty\npercent of the non-farm federal poverty level (as defined and updated by\nthe United States department of health and human services) shall be\nvoluntary and an eligible child may disenroll from the premium\nassistance program at any time and enroll in individual coverage under\nthis title; and\n (B) participation in the program for a child who resides in a\nhousehold having a household income between two hundred fifty-one and\nfour hundred percent of the non-farm federal poverty level (as defined\nand updated by the United States department of health and human\nservices) and meets certain eligibility criteria shall be mandatory. A\nchild in this income group who meets the criteria for enrollment in the\npremium assistance program shall not be eligible for individual coverage\nunder this title;\n (ii) standards for required levels of employer contributions toward\nthe cost of premiums for family coverage;\n (iii) standards for the level of state payment toward the cost of\npremiums for family coverage;\n (iv) standards for the scope and level of benefits to be provided in\nthe premium assistance program;\n (v) standards for data collection including, but not limited to, data\nregarding the substitution of health insurance coverage that would be\nprovided to eligible children in the absence of family coverage\npurchased pursuant to this subdivision; and\n (vi) any other standards deemed necessary by the commissioner to\nimplement the premium assistance program.\n (c) The state share of the cost of the premium assistance program, if\nimplemented, shall be funded within amounts appropriated for the purpose\nof providing healthcare coverage for uninsured and underinsured children\npursuant to this title.\n 19. Claims submitted to an approved organization for payment for\nmedical care, services, or supplies furnished by an out-of-network\nhealth care provider must be submitted within fifteen months of the date\nthe medical care, services, or supplies were furnished to an eligible\nperson to be valid and enforceable against the approved organization. If\na claim by an out-of-network health care provider is not submitted\nwithin fifteen months of the date that the medical care, services or\nsupplies were furnished and the claim is subsequently denied by the\napproved organization for that reason, such out-of-network health care\nprovider shall not seek payment for such medical care, services or\nsupplies from the enrollee. This deadline for claims submission shall\nnot apply where the claims submission is warranted to address findings\nor recommendations identified in a state or federal audit except where\nsuch audit also indicates that an inappropriate provider payment was\nsolely the fault of the out-of-network health care provider.\n 20. For approved organizations with negotiated rates of payment for\ninpatient hospital services under contracts in effect on April first,\ntwo thousand eight, that have a payment rate methodology for such\ninpatient hospital services that utilizes rates calculated by the\ndepartment of health pursuant to paragraph (a) or (a-2) of subdivision\none of section twenty-eight hundred seven-c of the public health law for\npatients under the medical assistance program, such rate shall not\ninclude adjustments pursuant to subdivision thirty-three of section\ntwenty-eight hundred seven-c of this chapter for contract periods prior\nto January first, two thousand ten.\n 21. The commissioner may make any necessary amendments to a contract\npursuant to this section with an approved organization, as defined in\nsubdivision two of section twenty-five hundred ten of this title, to\nallow such approved organization to participate as a qualified health\nplan in a state health benefit exchange established pursuant to the\nfederal Patient Protection and Affordable Care Act (P.L. 111-148), as\namended by the federal Health Care and Education Reconciliation Act of\n2010 (P.L. 111-152).\n 22. Notwithstanding the provisions of this title and effective on and\nafter January first, two thousand twenty-three, the consultative,\nreview, and approval functions of the superintendent of financial\nservices related to administration of the child health insurance plan\nare no longer applicable and references to those functions in this title\nshall be null and void. The child health insurance plan set forth in\nthis title shall be administered solely by the commissioner. All child\nhealth insurance plan policies reviewed and approved by the\nsuperintendent of financial services in accordance with section eleven\nhundred twenty of the insurance law shall remain in effect until the\ncommissioner establishes a process to review and approve member\nhandbooks in accordance with the requirements of Title XXI of the\nfederal social security act and implementing regulations, and such\nmember handbooks are issued by approved organizations to enrollees in\nplace of child health insurance plan policies which were subject to\nreview under section eleven hundred twenty of the insurance law.\n