§ 369-GG — Basic health program

New York § 369-GG

• Jurisdiction: New York
• Law SOS: Social Services
• Title 11-D: Essential Plan
• Art. 5: Assistance and Care

Text

§ 369-gg. Basic health program. 1. Definitions. For purposes of this\nsection:\n (a) "Eligible organization" means an insurer licensed pursuant to\narticle thirty-two or forty-two of the insurance law, a corporation or\nan organization under article forty-three of the insurance law, or an\norganization certified under article forty-four of the public health\nlaw, including providers certified under section forty-four hundred\nthree-e of the public health law;\n (b) "Approved organization" means an eligible organization approved by\nthe commissioner to underwrite a basic health insurance plan pursuant to\nthis title;\n * (c) "Health care services" means (i) the services and supplies as\ndefined by the commissioner in consultation with the superintendent of\nfinancial services, and shall be consistent with and subject to the\nessential health benefits as defined by the commissioner in accordance\nwith the provisions of the patient protection and affordable care act\n(P.L. 111-148) and consistent with the benefits provided by the\nreference plan selected by the commissioner for the purposes of defining\nsuch benefits, and shall include coverage of and access to the services\nof any national cancer institute-designated cancer center licensed by\nthe department of health within the service area of the approved\norganization that is willing to agree to provide cancer-related\ninpatient, outpatient and medical services to all enrollees in approved\norganizations' plans in such cancer center's service area under the\nprevailing terms and conditions that the approved organization requires\nof other similar providers to be included in the approved organization's\nnetwork, provided that such terms shall include reimbursement of such\ncenter at no less than the fee-for-service medicaid payment rate and\nmethodology applicable to the center's inpatient and outpatient\nservices; (ii) dental and vision services as defined by the\ncommissioner, and (iii) as defined by the commissioner and subject to\nfederal approval, certain services and supports provided to enrollees\neligible pursuant to subparagraph one of paragraph (g) of subdivision\none of section three hundred sixty-six of this article who have\nfunctional limitations and/or chronic illnesses that have the primary\npurpose of supporting the ability of the enrollee to live or work in the\nsetting of their choice, which may include the individual's home, a\nworksite, or a provider-owned or controlled residential setting;\n * NB Effective until December 31, 2030\n * (c) "Health care services" means (i) the services and supplies as\ndefined by the commissioner in consultation with the superintendent of\nfinancial services, and shall be consistent with and subject to the\nessential health benefits as defined by the commissioner in accordance\nwith the provisions of the patient protection and affordable care act\n(P.L. 111-148) and consistent with the benefits provided by the\nreference plan selected by the commissioner for the purposes of defining\nsuch benefits, and shall include coverage of and access to the services\nof any national cancer institute-designated cancer center licensed by\nthe department of health within the service area of the approved\norganization that is willing to agree to provide cancer-related\ninpatient, outpatient and medical services to all enrollees in approved\norganizations' plans in such cancer center's service area under the\nprevailing terms and conditions that the approved organization requires\nof other similar providers to be included in the approved organization's\nnetwork, provided that such terms shall include reimbursement of such\ncenter at no less than the fee-for-service medicaid payment rate and\nmethodology applicable to the center's inpatient and outpatient\nservices; and (ii) dental and vision services as defined by the\ncommissioner, and (iii) as defined by the commissioner and subject to\nfederal approval, certain services and supports provided to enrollees\nwho have functional limitations and/or chronic illnesses that have the\nprimary purpose of supporting the ability of the enrollee to live or\nwork in the setting of their choice, which may include the individual's\nhome, a worksite, or a provider-owned or controlled residential setting;\n * NB Effective January 1, 2031 until January 1, 2028\n * (c) "Health care services" means (i) the services and supplies as\ndefined by the commissioner in consultation with the superintendent of\nfinancial services, and shall be consistent with and subject to the\nessential health benefits as defined by the commissioner in accordance\nwith the provisions of the patient protection and affordable care act\n(P.L. 111-148) and consistent with the benefits provided by the\nreference plan selected by the commissioner for the purposes of defining\nsuch benefits, and (ii) as defined by the commissioner and subject to\nfederal approval, certain services and supports provided to enrollees\nwho have functional limitations and/or chronic illnesses that have the\nprimary purpose of supporting the ability of the enrollee to live or\nwork in the setting of their choice, which may include the individual's\nhome, a worksite, or a provider-owned or controlled residential setting;\n * NB Effective January 1, 2028 if federal approval is withdrawn or 42\nU.S.C. 18051 is repealed\n (d) "Qualified health plan" means a health plan that meets the\ncriteria for certification described in § 1311(c) of the Patient\nProtection and Affordable Care Act (P.L. 111-148), and is offered to\nindividuals through the health insurance exchange marketplace; and\n * (e) "Basic health insurance plan" means a standard health plan\nproviding health care services, separate and apart from qualified health\nplans, that is issued by an approved organization and certified in\naccordance with this section.\n * NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n * (e) "Basic health insurance plan" means a standard health plan,\nseparate and apart from qualified health plans, that is issued by an\napproved organization and certified in accordance with this section.\n * NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n 2. Authorization. If it is in the financial interest of the state to\ndo so, the commissioner of health is authorized, with the approval of\nthe director of the budget, to establish a basic health program. The\ncommissioner's authority pursuant to this section is contingent upon\nobtaining and maintaining all necessary approvals from the secretary of\nhealth and human services to offer a basic health program in accordance\nwith 42 U.S.C. 18051. The commissioner may take any and all actions\nnecessary to obtain such approvals. Notwithstanding the foregoing,\nwithin ninety days of the effective date of the chapter of the laws of\ntwo thousand fifteen which amended this subdivision the commissioner\nshall submit a report to the temporary president of the senate and the\nspeaker of the assembly detailing a contingency plan in the event\neligibility rules or regulations are modified or repealed; or in the\nevent federal payment is reduced from ninety five percent of the premium\ntax credits and cost-sharing reductions pursuant to the patient\nprotection and affordable care act (P.L. 111-148). The contingency plan\nshall be implemented within ninety days of the above stated events or\nthe time period specified in federal law.\n 3. Eligibility. A person is eligible to receive coverage for health\ncare services pursuant to this title if he or she:\n (a) resides in New York state and is under sixty-five years of age;\n (b) is not eligible for medical assistance under title eleven of this\narticle or for the child health insurance plan described in title one-A\nof article twenty-five of the public health law;\n (c) is not eligible for minimum essential coverage, as defined in\nsection 5000A(f) of the Internal Revenue Service Code of 1986, or is\neligible for an employer-sponsored plan that is not affordable, in\naccordance with section 5000A of such code; and\n * (d) (i) except as provided by subparagraph (ii) of this paragraph,\nhas household income at or below two hundred percent of the federal\npoverty line defined and annually revised by the United States\ndepartment of health and human services for a household of the same\nsize; and has household income that exceeds one hundred thirty-three\npercent of the federal poverty line defined and annually revised by the\nUnited States department of health and human services for a household of\nthe same size; however, MAGI eligible noncitizens lawfully present in\nthe United States with household incomes at or below one hundred\nthirty-three percent of the federal poverty line shall be eligible to\nreceive coverage for health care services pursuant to the provisions of\nthis title if such noncitizen would be ineligible for medical assistance\nunder title eleven of this article due to their immigration status;\n (ii) subject to federal approval and the use of state funds, unless\nthe commissioner may use funds under subdivision seven of this section,\nhas household income at or below two hundred fifty percent of the\nfederal poverty line defined and annually revised by the United States\ndepartment of health and human services for a household of the same\nsize; and has household income that exceeds one hundred thirty-three\npercent of the federal poverty line defined and annually revised by the\nUnited States department of health and human services for a household of\nthe same size; however, MAGI eligible aliens lawfully present in the\nUnited States with household incomes at or below one hundred\nthirty-three percent of the federal poverty line shall be eligible to\nreceive coverage for health care services pursuant to the provisions of\nthis title if such alien would be ineligible for medical assistance\nunder title eleven of this article due to their immigration status;\n (iii) subject to federal approval if required and the use of state\nfunds, unless the commissioner may use funds under subdivision seven of\nthis section, a pregnant individual who is eligible for and receiving\ncoverage for health care services pursuant to this title is eligible to\ncontinue to receive health care services pursuant to this title during\nthe pregnancy and for a period of one year following the end of the\npregnancy without regard to any change in the income of the household\nthat includes the pregnant individual, even if such change would render\nthe pregnant individual ineligible to receive health care services\npursuant to this title;\n (iv) subject to federal approval, a child born to an individual\neligible for and receiving coverage for health care services pursuant to\nthis title who would be eligible for coverage pursuant to subparagraphs\n(2) or (4) of paragraph (b) of subdivision 1 of section three hundred\nand sixty-six of the social services law shall be deemed to have applied\nfor medical assistance and to have been found eligible for such\nassistance on the date of such birth and to remain eligible for such\nassistance for a period of one year.\n An applicant who fails to make an applicable premium payment, if any,\nshall lose eligibility to receive coverage for health care services in\naccordance with time frames and procedures determined by the\ncommissioner.\n * NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n * (d) (i) except as provided by subparagraph (ii) of this paragraph,\nhas household income at or below two hundred percent of the federal\npoverty line defined and annually revised by the United States\ndepartment of health and human services for a household of the same\nsize; and has household income that exceeds one hundred thirty-three\npercent of the federal poverty line defined and annually revised by the\nUnited States department of health and human services for a household of\nthe same size; however, MAGI eligible noncitizens lawfully present in\nthe United States with household incomes at or below one hundred\nthirty-three percent of the federal poverty line shall be eligible to\nreceive coverage for health care services pursuant to the provisions of\nthis title if such noncitizen would be ineligible for medical assistance\nunder title eleven of this article due to their immigration status;\n (ii) subject to federal approval and the use of state funds, unless\nthe commissioner may use funds under subdivision seven of this section,\nhas household income at or below two hundred fifty percent of the\nfederal poverty line defined and annually revised by the United States\ndepartment of health and human services for a household of the same\nsize; and has household income that exceeds one hundred thirty-three\npercent of the federal poverty line defined and annually revised by the\nUnited States department of health and human services for a household of\nthe same size; however, MAGI eligible aliens lawfully present in the\nUnited States with household incomes at or below one hundred\nthirty-three percent of the federal poverty line shall be eligible to\nreceive coverage for health care services pursuant to the provisions of\nthis title if such alien would be ineligible for medical assistance\nunder title eleven of this article due to their immigration status;\n (iii) subject to federal approval if required and the use of state\nfunds, unless the commissioner may use funds under subdivision seven of\nthis section, a pregnant individual who is eligible for and receiving\ncoverage for health care services pursuant to this title is eligible to\ncontinue to receive health care services pursuant to this title during\nthe pregnancy and for a period of one year following the end of the\npregnancy without regard to any change in the income of the household\nthat includes the pregnant individual, even if such change would render\nthe pregnant individual ineligible to receive health care services\npursuant to this title;\n (iv) subject to federal approval, a child born to an individual\neligible for and receiving coverage for health care services pursuant to\nthis title who would be eligible for coverage pursuant to subparagraphs\n(2) or (4) of paragraph (b) of subdivision 1 of section three hundred\nand sixty-six of the social services law shall be deemed to have applied\nfor medical assistance and to have been found eligible for such\nassistance on the date of such birth and to remain eligible for such\nassistance for a period of one year.\n An applicant who fails to make an applicable premium payment shall\nlose eligibility to receive coverage for health care services in\naccordance with time frames and procedures determined by the\ncommissioner.\n * NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n 4. Enrollment. (a) Subject to federal approval, the commissioner is\nauthorized to establish an application and enrollment procedure for\nprospective enrollees. Such procedure shall include a verification\nsystem for applicants, which shall be consistent with 42 USC § 1320b-7.\n (b) Such procedure shall allow for continuous enrollment for enrollees\nto the basic health program where an individual may apply and enroll for\ncoverage at any point.\n (c) Upon an applicant's enrollment in a basic health insurance plan,\ncoverage for health care services pursuant to the provisions of this\ntitle shall be prospective. Coverage shall begin in a manner consistent\nwith the requirements for qualified health plans offered through the\nhealth insurance exchange marketplace, as delineated in federal\nregulation at 42 CFR 155.420(b)(1) or any successor regulation thereof.\n (d) A person who has enrolled for coverage pursuant to this title, and\nwho loses eligibility to enroll in the basic health program for a reason\nother than citizenship status, lack of state residence, failure to\nprovide a valid social security number, providing inaccurate information\nthat would affect eligibility when requesting or renewing health\ncoverage pursuant to this title, or failure to make an applicable\npremium payment, before the end of a twelve month period beginning on\nthe effective date of the person's initial eligibility for coverage, or\nbefore the end of a twelve month period beginning on the date of any\nsubsequent determination of eligibility, shall have his or her\neligibility for coverage continued until the end of such twelve month\nperiod, provided that the state receives federal approval for using\nfunds from the basic health program trust fund, established under\nsection 97-oooo of the state finance law, for the costs associated with\nsuch assistance.\n * 5. Premiums and cost sharing. (a) Subject to federal approval, the\ncommissioner shall establish premium payments enrollees shall pay to\napproved organizations for coverage of health care services pursuant to\nthis title. No payment is required for individuals with a household\nincome at or below two hundred percent of the federal poverty line\ndefined and annually revised by the United States department of health\nand human services for a household of the same size.\n (b) The commissioner shall establish cost sharing obligations for\nenrollees, subject to federal approval. There shall be no cost-sharing\nobligations for enrollees for dental and vision services as defined in\nsubparagraph (ii) of paragraph (c) of subdivision one of this section;\nservices and supports as defined in subparagraph (iii) of paragraph (c)\nof subdivision one of this section; and health care services authorized\nunder subparagraphs (iii) and (iv) of paragraph (d) of subdivision three\nof this section.\n * NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n * 5. Premiums and cost sharing. (a) Subject to federal approval, the\ncommissioner shall establish premium payments enrollees shall pay to\napproved organizations for coverage of health care services pursuant to\nthis title. Such premium payments shall be established in the following\nmanner:\n (i) up to twenty dollars monthly for an individual with a household\nincome above one hundred and fifty percent of the federal poverty line\nbut at or below two hundred percent of the federal poverty line defined\nand annually revised by the United States department of health and human\nservices for a household of the same size; and\n (ii) no payment is required for individuals with a household income at\nor below one hundred and fifty percent of the federal poverty line\ndefined and annually revised by the United States department of health\nand human services for a household of the same size.\n (b) The commissioner shall establish cost sharing obligations for\nenrollees, subject to federal approval. There shall be no cost-sharing\nobligations for services and supports as defined in subparagraph (iii)\nof paragraph (c) of subdivision one of this section; and health care\nservices authorized under subparagraphs (iii) and (iv) of paragraph (d)\nof subdivision three of this section.\n * NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n 6. Rates of payment. (a) The commissioner shall select the contract\nwith an independent actuary to study and recommend appropriate\nreimbursement methodologies for the cost of health care service coverage\npursuant to this title. Such independent actuary shall review and make\nrecommendations concerning appropriate actuarial assumptions relevant to\nthe establishment of reimbursement methodologies, including but not\nlimited to; the adequacy of rates of payment in relation to the\npopulation to be served adjusted for case mix, the scope of health care\nservices approved organizations must provide, the utilization of such\nservices and the network of providers required to meet state standards.\n (b) Upon consultation with the independent actuary and entities\nrepresenting approved organizations, the commissioner shall develop\nreimbursement methodologies and fee schedules for determining rates of\npayment, which rate shall be approved by the director of the division of\nthe budget, to be made by the department to approved organizations for\nthe cost of health care services coverage pursuant to this title. Such\nreimbursement methodologies and fee schedules may include provisions for\ncapitation arrangements.\n (c) The commissioner shall have the authority to promulgate\nregulations, including emergency regulations, necessary to effectuate\nthe provisions of this subdivision.\n (d) The department shall require the independent actuary selected\npursuant to paragraph (a) of this subdivision to provide a complete\nactuarial report, along with all actuarial assumptions made and all\nother data, materials and methodologies used in the development of rates\nfor the basic health plan authorized under this section. Such report\nshall be provided annually to the temporary president of the senate and\nthe speaker of the assembly.\n * 7. Any funds transferred by the secretary of health and human\nservices to the state pursuant to 42 U.S.C. 18051(d) shall be deposited\nin trust. Funds from the trust shall be used for providing health\nbenefits through an approved organization, which, at a minimum, shall\ninclude essential health benefits as defined in 42 U.S.C. 18022(b); to\nreduce the premiums, if any, and cost sharing of participants in the\nbasic health program; or for such other purposes as may be allowed by\nthe secretary of health and human services. Health benefits available\nthrough the basic health program shall be provided by one or more\napproved organizations pursuant to an agreement with the department of\nhealth and shall meet the requirements of applicable federal and state\nlaws and regulations.\n * NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n * 7. Any funds transferred by the secretary of health and human\nservices to the state pursuant to 42 U.S.C. 18051(d) shall be deposited\nin trust. Funds from the trust shall be used for providing health\nbenefits through an approved organization, which, at a minimum, shall\ninclude essential health benefits as defined in 42 U.S.C. 18022(b); to\nreduce the premiums and cost sharing of participants in the basic health\nprogram; or for such other purposes as may be allowed by the secretary\nof health and human services. Health benefits available through the\nbasic health program shall be provided by one or more approved\norganizations pursuant to an agreement with the department of health and\nshall meet the requirements of applicable federal and state laws and\nregulations.\n * NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is\nrepealed\n 8. An individual who is lawfully admitted for permanent residence,\npermanently residing in the United States under color of law, or who is\na non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C.\n1101(a)(15), and who would be ineligible for medical assistance under\ntitle eleven of this article due to his or her immigration status if the\nprovisions of section one hundred twenty-two of this chapter were\napplied, shall be considered to be ineligible for medical assistance for\npurposes of paragraphs (b) and (c) of subdivision three of this section.\n 9. Reporting. The commissioner shall submit a report to the temporary\npresident of the senate and the speaker of the assembly annually by\nDecember thirty-first. The report shall include, at a minimum, an\nanalysis of the basic health program and its impact on the financial\ninterest of the state; its impact on the health benefit exchange\nincluding enrollment and premiums; its impact on the number of uninsured\nindividuals in the state; its impact on the Medicaid global cap; and the\ndemographics of basic health program enrollees including age and\nimmigration status.\n