§ 268-D — Special functions of the Marketplace related to health plan certification and qualified health plan oversight

New York § 268-D

• Jurisdiction: New York
• Law PBH: Public Health
• Title 7: Ny State of Health
• Art. 2: The Department of Health

Text

§ 268-d. Special functions of the Marketplace related to health plan\ncertification and qualified health plan oversight. 1. Health plans\ncertified by the Marketplace shall meet the following requirements:\n (a) The insurer offering the health plan:\n (i) is licensed or certified by the superintendent or commissioner, in\ngood standing to offer health insurance coverage in this state, and\nmeets the requirements established by the Marketplace;\n (ii) offers at least one qualified health plan and/or other or\nadditional health plans authorized for sale by the department of\nfinancial services or the department in each of the silver and gold\nlevels as required by state law, provided, however, that the Marketplace\nmay require additional benefit levels to be offered by all insurers\nparticipating in the Marketplace;\n (iii) has filed with and received approval from the superintendent of\nits premium rates and policy or contract forms pursuant to the insurance\nlaw and/or this chapter;\n (iv) does not charge any cancellation fees or penalties for\ntermination of coverage in violation of applicable law; and\n (v) complies with the regulations developed by the secretary under\nsection 1311(c) of the federal act and such other requirements as the\nMarketplace may establish.\n (b) The health plan: (i) provides the essential health benefits\npackage described in state law or required by the Marketplace and\nincludes such additional benefits as are mandated by state law, except\nthat the health plan shall not be required to provide essential benefits\nthat duplicate the minimum benefits of qualified dental plans if:\n (A) the Marketplace has determined that at least one qualified dental\nplan or dental plan approved by the department of financial services or\nthe department is available to supplement the health plan's coverage;\nand\n (B) the insurer makes prominent disclosure at the time it offers the\nhealth plan, in a form approved by the Marketplace, that the plan does\nnot provide the full range of essential pediatric benefits, and that\nqualified dental plans or dental plans approved by the department of\nfinancial services or department of health providing those benefits and\nother dental benefits not covered by the plan are offered through the\nMarketplace;\n (ii) provides at least a bronze level of coverage as defined by state\nlaw, unless the plan is certified as a qualified catastrophic plan, as\ndefined in section 1302(e) of the federal act and the insurance law, and\nshall only be offered to individuals eligible for catastrophic coverage;\n (iii) has cost-sharing requirements, including deductibles, which do\nnot exceed the limits established under section 1302(c) of the federal\nact, state law and any requirements of the Marketplace;\n (iv) complies with regulations promulgated by the secretary pursuant\nto section 1311(c) of the federal act and applicable state law, which\ninclude minimum standards in the areas of marketing practices, network\nadequacy, essential community providers in underserved areas,\naccreditation, quality improvement, uniform enrollment forms and\ndescriptions of coverage and information on quality measures for health\nbenefit plan performance;\n * (v) meets standards specified and determined by the Marketplace,\nprovided that the standards do not conflict with or prevent the\napplication of federal requirements;\n * NB Effective until January 1, 2028\n * (v) meets standards specified and determined by the Marketplace,\nprovided that the standards do not conflict with or prevent the\napplication of federal requirements; and\n * NB Effective January 1, 2028\n * (vi) contracts with any national cancer institute-designated cancer\ncenter licensed by the department within the health plan's service area\nthat is willing to agree to provide cancer-related inpatient, outpatient\nand medical services to enrollees in all health plans offering coverage\nthrough the Marketplace in such cancer center's service area under the\nprevailing terms and conditions that the plan requires of other similar\nproviders to be included in the plan's provider network, provided that\nsuch terms shall include reimbursement of such center at no less than\nthe fee-for-service medicaid payment rate and methodology applicable to\nthe center's inpatient and outpatient services; and\n * NB Effective until January 1, 2028\n * (vi) complies with the insurance law and this chapter requirements\napplicable to health insurance issued in this state and any regulations\npromulgated pursuant thereto that do not conflict with or prevent the\napplication of federal requirements; and\n * NB Effective January 1, 2028\n * (vii) complies with the insurance law and this chapter requirements\napplicable to health insurance issued in this state and any regulations\npromulgated pursuant thereto that do not conflict with or prevent the\napplication of federal requirements; and\n * NB Repealed January 1, 2028\n (c) The Marketplace determines that making the health plan available\nthrough the Marketplace is in the interest of qualified individuals in\nthis state.\n 2. The Marketplace shall not exclude a health plan:\n (a) on the basis that the health plan is a fee-for-service plan;\n (b) through the imposition of premium price controls by the\nMarketplace; or\n (c) on the basis that the health plan provides treatments necessary to\nprevent patients' deaths in circumstances the Marketplace determines are\ninappropriate or too costly.\n 3. The Marketplace shall require each insurer certified or seeking\ncertification of a health plan as a qualified health plan or plan\napproved for sale by the department of financial services or the\ndepartment to:\n (a) submit a justification for any premium increase pursuant to\napplicable law prior to implementation of such increase. The insurer\nshall prominently post the information on its internet website. Such\nrate increases shall be subject to the prior approval of the\nsuperintendent pursuant to the insurance law;\n (b)(i) make available to the public and submit to the Marketplace, the\nsecretary and the superintendent, accurate and timely disclosure of:\n (A) claims payment policies and practices;\n (B) periodic financial disclosures;\n (C) data on enrollment and disenrollment;\n (D) data on the number of claims that are denied;\n (E) data on rating practices;\n (F) information on cost-sharing and payments with respect to any\nout-of-network coverage;\n (G) information on enrollee and participant rights under title I of\nthe federal act; and\n (H) other information as determined appropriate by the secretary or\notherwise required by the Marketplace;\n (ii) the information shall be provided in plain language, as that term\nis defined in section 1311(e)(3)(B) of the federal act and state law,\nand in guidance jointly issued thereunder by the secretary and the\nfederal secretary of labor; and\n (c) provide to individuals, in a timely manner upon the request of the\nindividual, the amount of cost-sharing, including deductibles,\ncopayments, and coinsurance, under the individual's health plan or\ncoverage that the individual would be responsible for paying with\nrespect to the furnishing of a specific item or service by a\nparticipating provider. At a minimum, this information shall be made\navailable to the individual through an internet website and through\nother means for individuals without access to the internet.\n 4. The Marketplace shall not exempt any insurer seeking certification\nof a health plan, regardless of the type or size of the insurer, from\nlicensing or solvency requirements under the insurance law or this\nchapter, and shall apply the criteria of this section in a manner that\nensures a level playing field for insurers participating in the\nMarketplace.\n 5. (a) The provisions of this article that apply to qualified health\nplans and plans approved for sale by the department of financial\nservices and the department also shall apply to the extent relevant to\nqualified dental plans approved for sale by the department of financial\nservices or the department, except as modified in accordance with the\nprovisions of paragraphs (b) and (c) of this subdivision or otherwise\nrequired by the Marketplace.\n (b) The qualified dental plan or dental plan approved for sale by the\ndepartment of financial services and/or the department shall be limited\nto dental and oral health benefits, without substantially duplicating\nthe benefits typically offered by health benefit plans without dental\ncoverage, and shall include, at a minimum, the essential pediatric\ndental benefits prescribed by the secretary pursuant to section\n1302(b)(1)(J) of the federal act, and such other dental benefits as the\nMarketplace or secretary may specify in regulations.\n (c) Insurers may jointly offer a comprehensive plan through the\nMarketplace in which an insurer provides the dental benefits through a\nqualified dental plan or plan approved by the department of financial\nservices or the department and an insurer provides the other benefits\nthrough a qualified health plan, provided that the plans are priced\nseparately and also are made available for purchase separately at the\nsame price.\n