§ 268-C — Functions of the Marketplace

§ 268-c. Functions of the Marketplace. The Marketplace shall:\n 1. (a) Perform eligibility determinations for federal and state\ninsurance affordability programs including medical assistance in\naccordance with section three hundred sixty-six of the social services\nlaw, child health plus in accordance with section twenty-five hundred\neleven of this chapter, the basic health program in accordance with\nsection three hundred sixty-nine-gg of the social services law, the 1332\nstate innovation program in accordance with section three hundred\nsixty-nine-ii of the social services law, premium tax credits and\ncost-sharing reductions and qualified health plans in accordance with\napplicable law and other health insurance programs as determined by the\ncommissioner;\n (b) certify and make available to qualified individuals, qualified\nhealth plans, including dental plans, certified by the Marketplace\npursuant to applicable law, provided that coverage under such plans\nshall not become effective prior to certification by the Marketplace;\nand\n (c) certify and/or make available to eligible individuals, health\nplans certified by the Marketplace pursuant to applicable law, and/or\nparticipating in an insurance affordability program pursuant to\napplicable law, provided that coverage under such plans shall not become\neffective prior to certification by the Marketplace, and/or approval by\nthe commissioner.\n 2. Assign an actuarial value to each Marketplace certified plan\noffered through the Marketplace in accordance with the criteria\ndeveloped by the secretary pursuant to federal law or the superintendent\npursuant to the insurance law and/or requirements developed by the\nMarketplace, and determine each health plan's level of coverage in\naccordance with regulations issued by the secretary pursuant to federal\nlaw or the superintendent pursuant to the insurance law.\n 3. Utilize a standardized format for presenting health benefit options\nin the Marketplace, including the use of the uniform outline of coverage\nestablished under section 2715 of the federal public health service act\nor the insurance law.\n 4. Standardize the benefits available through the Marketplace at each\nlevel of coverage defined by the superintendent in the insurance law.\n 5. Maintain enrollment periods in the best interest of qualified\nindividuals consistent with federal and state law.\n 6. Implement procedures for the certification, recertification and\ndecertification of health plans as qualified health plans or health\nplans approved for sale by the department of financial services or\ndepartment of health and certified by the Marketplace, consistent with\nguidelines developed by the secretary pursuant to section 1311(c) of the\nfederal act and requirements developed by the Marketplace.\n 7. Contract for health care coverage offered to qualified individuals\nthrough the Marketplace, and in doing so shall seek to provide health\ncare coverage choices that offer the optimal combination of choice,\nvalue, quality, and service.\n 8. Contract for health care coverage offered to certain eligible\nindividuals through the Marketplace, pursuant to health insurance\nprograms as determined by the commissioner, and in doing so shall seek\nto provide health care coverage choices that offer the optimal\ncombination of choice, value, quality, and service;\n 9. Provide the minimum requirements an insurer shall meet to\nparticipate in the Marketplace, in the best interest of qualified\nindividuals or eligible individuals;\n 10. Require qualified health plans and/or other health plans certified\nby the Marketplace to offer those benefits determined to be essential\nhealth benefits pursuant to state law or as required by the Marketplace.\n 11. Ensure that insurers offering health plans through the Marketplace\ndo not charge an individual enrollee a fee or penalty for termination of\ncoverage.\n 12. Provide for the operation of a toll-free telephone hotline to\nrespond to requests for assistance.\n 13. Maintain an internet website through which enrollees and\nprospective enrollees of qualified health plans and health plans\ncertified by the Marketplace may obtain standardized comparative\ninformation on such plans and insurance affordability programs.\n 14. Make available by electronic means a calculator to determine the\nactual cost of coverage after the application of any premium tax credit\nunder section 36B of the Internal Revenue Code of 1986 or applicable\nstate law and any cost-sharing reduction under federal or applicable\nstate law.\n 15. Operate a program under which the Marketplace awards grants to\nentities to serve as navigators in accordance with applicable federal\nlaw and regulations adopted thereunder, and/or a program under which the\nMarketplace awards grants to entities to provide community based\nenrollment assistance in accordance with requirements developed by the\nMarketplace; and/or a program under which the Marketplace certifies New\nYork state licensed producers to provide assistance to eligible\nindividuals and/or small employers pursuant to federal or state law.\n 16. In accordance with applicable federal and state law, inform\nindividuals of eligibility requirements for the Medicaid program under\ntitle XIX of the social security act and the social services law, the\nchildren's health insurance program (CHIP) under title XXI of the social\nsecurity act and this chapter, the basic health program under section\nthree hundred sixty-nine-gg of the social services law, the 1332 state\ninnovation program in accordance with section three hundred\nsixty-nine-ii of the social services law, or any applicable state or\nlocal public health insurance program and if, through screening of the\napplication by the Marketplace, the Marketplace determines that such\nindividuals are eligible for any such program, enroll such individuals\nin such program.\n 17. Grant a certification that an individual is exempt from the\nrequirement to maintain minimum essential coverage pursuant to federal\nor state law and from any penalties imposed by such requirements\nbecause:\n (a) there is no affordable health plan available covering the\nindividual, as defined by applicable law; or\n (b) the individual meets the requirements for any other such exemption\nfrom the requirement to maintain minimum essential coverage or to pay\nthe penalty pursuant to applicable federal or state law.\n 18. Operate a small business health options program ("SHOP") pursuant\nto section 1311 of the federal act and applicable state law, through\nwhich eligible small employers may select marketplace-certified\nqualified health plans offered in the small group market, and through\nwhich eligible small employers may receive assistance in qualifying for\nsmall business tax credits available pursuant to federal and state law.\n 19. Enter into agreements as necessary with federal and state agencies\nand other state Marketplaces to carry out its responsibilities under\nthis title, provided such agreements include adequate protections with\nrespect to the confidentiality of any information to be shared and\ncomply with all state and federal laws and regulations.\n 20. Perform duties required by the secretary, the secretary of the\nUnited States department of the treasury or the commissioner related to\ndetermining eligibility for premium tax credits or reduced cost-sharing\nunder applicable federal or state law.\n 21. Meet program integrity requirements under applicable law,\nincluding keeping an accurate accounting of receipts and expenditures\nand providing reports to the secretary regarding Marketplace related\nactivities in accordance with applicable law.\n 22. Submit information provided by Marketplace applicants for\nverification as required by section 1411(c) of the federal act and\napplicable state law.\n 23. Establish rules and regulations that do not conflict with or\nprevent the application of regulations promulgated by the secretary.\n 24. Determine eligibility, provide notices, and provide opportunities\nfor appeal and redetermination in accordance with the requirements of\nfederal and state law.\n 25. The commissioner is authorized to submit the appropriate waiver\napplications to the United States secretary of health and human services\nand/or the department of the treasury to waive any applicable provisions\nof the Patient Protection and Affordable Care Act, Pub. L. 111-148 as\namended, or successor provisions, as provided for by 42 U.S.C. 18052,\nand any other waivers necessary to achieve the purposes of high quality,\naffordable coverage through NY State of Health, the official health plan\nmarketplace. The commissioner shall implement the state plans of any\nsuch waiver in a manner consistent with applicable state and federal\nlaws, as authorized by the secretary of health and human services and/or\nthe secretary of the treasury pursuant to 42 U.S.C. 18052. Copies of\nsuch original waiver applications and amendments thereto shall be\nprovided to the chair of the senate finance committee, the chair of the\nassembly ways and means committee and the chairs of the senate and\nassembly health committees simultaneously with their submission to the\nfederal government.\n * 26. Subject to federal approval if required, the use of state funds\nand the availability of funds in the 1332 state innovation program fund\nestablished pursuant to section ninety-eight-d of the state finance law,\nthe commissioner shall have the authority to establish a program to\nprovide subsidies for the payment of premium or cost sharing or both to\nassist individuals who are eligible to purchase qualified health plans\nthrough the marketplace, or take such other action as appropriate to\nreduce or eliminate qualified health plan premiums or cost-sharing or\nboth.\n * NB Effective upon the commissioner of health obtaining and\nmaintaining certain approvals (see chapter 57 of 2024 Pt. J § 10)\n