N.Y. Expanded Health Care Coverage Act 703/88 § 4: Regional pilot projects for the uninsured

§ 4. Regional pilot projects for the uninsured. 1. The commissioner,

in consultation with the subcommittee, is authorized to conduct regional

pilot projects, including one or more individual subsidy programs and

one or more employer incentive programs. The commissioner shall approve

at least one of each program in accordance with subdivision five of this

section. In the absence of applications which meet the approval criteria

for any one model, the commissioner may approve additional programs in

the other program category.

2. (a) An individual subsidy program shall assist individuals and

families in purchasing health care coverage under insurance or

equivalent coverage mechanisms. In order to be eligible for

participation in the program, and subject to annual recertification of

eligibility, individuals and families shall meet the following criteria:

(i) gross household income is at or below two hundred percent of the

non-farm federal poverty level; and

(ii) not receiving medical assistance without taking into account

costs incurred for medical care under the provisions of section three

hundred sixty-six of the social services law; and

(iii) ineligible for medicare as defined in subchapter XVIII of the

federal Social Security Act, 42 U.S.C. §1395 et seq., and

(iv) do not have equivalent health care coverage under insurance or

equivalent coverage mechanisms as defined by the commissioner, in

consultation with the superintendent. Individuals and families having

health care coverage within the six month period prior to application

shall not be eligible for the individual subsidy program. The limitation

shall not apply to persons who become ineligible for medical assistance

or whose insurance or equivalent coverage is terminated as a result of

loss of employment within such period.

(b) If individuals and families receiving benefits under the

individual subsidy program become eligible for medical assistance by

taking into account costs incurred for medical care, social services

districts may pay all or part of the premium in accordance with

department of social services regulations. For the purpose of this

paragraph, subsidy payments shall not be available to cover the costs of

the premium.

(c) For the purposes of the individual subsidy program, subsidy

payments shall be made, under subdivision eight of this section, to an

approved organization for the purpose of reducing premium payments,

deductibles or copayments for participants in the program. The

commissioner may establish and adjust schedules of payments to be made

under this program. In determining such schedules, the costs to be borne

by the individual or family shall take into account the household size

and gross annual income of the household and such other factors as the

commissioner may deem appropriate.

(d) Notwithstanding the provisions of paragraph (a) of this

subdivision, an individual who meets the criteria as established in

subparagraphs (ii) through (iv) of such paragraph may be enrolled in the

individual subsidy program, provided however, that an approved

organization shall not be eligible to receive a subsidy payment for

providing coverage to such an individual. Enrollment of such individuals

shall not exceed twenty-five percent of the total enrollment for

participants in the individual subsidy program.

(e) Applications for enrollment in the individual subsidy program will

not be accepted on and after January first, two thousand one; provided,

however, individuals and families who are otherwise eligible to receive

benefits under such program and are enrolled prior to January first, two

thousand one, may remain enrolled in such program until March

thirty-first, two thousand nine.

3. (a) An employer incentive program shall assist employers of twenty

or fewer employees in purchasing health care coverage for all full-time

employees and such other employees determined to be qualified for such

coverage by the employer based on employment status. In order to

participate in the program, an employer shall not have, within the six

month period prior to application, provided employer-financed group

health care coverage to any employee associated with the employer's

business.

(b) An employer incentive payment shall consist of payments to an

approved organization in the amount of no more than fifty percent of the

premium costs for group health care coverage for employees and their

dependents. Employees shall not be required to make contributions to the

payment of premium costs under this program. Premium costs incurred by

an employer for group health insurance coverage for officers and

directors of an employer and others with a proprietary or ownership

interest in the employer may be eligible for an incentive payment to

offset premium costs; provided, however, that the gross household income

of such officers and directors or others with a propriety or ownership

interest does not exceed the limits provided pursuant to subparagraph

(i) of paragraph (a) of subdivision two of this section and provided

further that one or more employees and their dependents proposed to be

covered by such group health care coverage are unrelated to such

officers, directors or other persons with a propriety or ownership

interest. If an employer participating in an employer incentive program

hires more than twenty employees after joining the program, the employer

may continue in the program but the premium costs attributable to the

additional employees or their families shall not be eligible for

incentive payments.

(c) Employers may be approved to participate in the program based upon

the average salaries of the employees who are to receive health care

coverage, with those employers with the lowest average employee salaries

to be selected first and other employers to be eligible for

participation as funding will allow.

(d) Notwithstanding the provisions of this subdivision, if the number

of employers who meet the criteria established in paragraph (a) of this

subdivision, and who are applying for participation in the employer

subsidy program, exceeds the amount of funds available to an approved

organization to provide health care coverage to employers under the

program, the approved organization may enroll additional employers. The

approved organization shall not receive incentive payments for such

employers. Enrollment of such employers shall not exceed twenty-five

percent of the total enrollment of employers and their dependents

participating in the employer incentive program.

(e) Employer incentive programs established pursuant to this section

shall expire upon implementation of the New York state small business

health insurance partnership program in accordance with the provisions

of article 9-A of the public health law.

4. The commissioner shall establish guidelines for the submission of

proposals by eligible organizations, including, but not limited to, the

following components:

(i) standards for premiums, copayments and deductibles which consider

the needs of program participants in obtaining health care;

(ii) insurance or equivalent coverage mechanisms to be utilized under

the project;

(iii) minimum standards for benefits under the requirements of the

insurance law and such additional benefits as may be identified;

(iv) health care provider payment methodologies;

(v) appropriate utilization review and quality assurance mechanisms;

and

(vi) such other criteria which may be deemed necessary.

5. (a) A proposal submitted by an eligible organization shall meet the

following criteria:

(i) estimate the number of participants who would be eligible for the

program and the estimated number of actual participants in the program

location;

(ii) designate the geographic area to be served by the program;

(iii) assure access to and delivery of high quality, appropriate

medical services and include a network of health care providers in

sufficient numbers and geographically accessible to service program

participants;

(iv) describe the procedures for marketing and determining eligibility

for the health care coverage plan in the program location, including the

designation of other entities which may perform such functions under

contract with the organization;

(v) describe any arrangements for negotiated special payment rate

methodologies for inpatient and outpatient services;

(vi) describe in detail the estimated expenses, including the proposed

use of subsidy or incentive payments, personnel costs and other types of

administrative expenses which will be incurred in the development and

implementation of the program;

(vii) describe the quality assurance mechanisms and utilization review

mechanisms to be implemented;

(viii) demonstrate that the applicant has sought public participation

and local involvement in the development of the program plan;

(ix) demonstrate the applicant's ability to meet the data analysis and

reporting requirements for program evaluation;

(x) describe the extent to which the program may be replicated in

other geographic areas or on a statewide basis;

(xi) describe the benefit package to be offered in the program and the

cost of such benefit package;

(xii) comply with or demonstrate an acceptable arrangement or contract

with an organization which can meet the requirements of section eleven

hundred eighteen and other applicable provisions of the insurance law;

(xiii) demonstrate the financial feasibility of the program;

(xiv) describe the premium, copayments and deductibles to be paid by

program participants; and

(xv) include any other information the commissioner and the

superintendent shall deem appropriate.

(b) The commissioner, within forty-five days of receiving a proposal

from an eligible entity, shall make a determination whether to approve,

disapprove or recommend modification of the proposal. In order for a

proposal to be approved by the commissioner, the proposal must also be

approved by the superintendent with respect to the provisions of

subparagraphs (xii) through (xiv) of paragraph (a) of this subdivision.

Upon receiving a proposal, the commissioner shall provide a copy of the

proposal to the chairman of the subcommittee, consult with the

subcommittee and receive its recommendation with regard to such

application.

6. The commissioner, in consultation with the subcommittee, may

approve a supplemental grant program, in addition to those programs

authorized under subdivision five of this section, to provide grants for

public education, outreach and marketing of health care coverage

targeted at uninsured individuals and families and employers not

providing coverage to their employees in any geographic area which is

not designated for regional pilot project implementation. Grants may be

used for the following:

(i) public education concerning the availability of health care

coverage;

(ii) promotion of community awareness of the benefits of health care

coverage; and

(iii) outreach and direct recruitment of potential enrollees.

7. The commissioner is authorized to approve contracts between an

approved organization and any other organization for the purposes

including, but not limited to, outreach, marketing and eligibility

determination.

8. The commissioner shall determine the amount of funds to be

allocated to an approved organization for the purposes described in

subdivision one of this section from any funds available pursuant to

subparagraph (i) of paragraph (f) of subdivision nineteen of section

twenty-eight hundred seven-c of the public health law.

8-a. The commissioner, in consultation with the superintendent, may

adjust subsidy payments and incentive payments for approved programs for

any of the following circumstances: (a) for new programs; (b) for new

coverage under existing programs; and (c) to be effective on the next

annual renewal date of the affected coverage for existing coverage.

9. Notwithstanding the provisions of paragraph (c) of subdivision two

of section two thousand eight hundred seven-c of the public health law,

approved organizations may enter into agreements for negotiated payment

rate methodologies with general hospitals for inpatient and outpatient

hospital services. Such negotiated payment rate methodologies in the

case of inpatient services or outpatient services shall be subject to

the approval of the commissioner, and shall not adversely affect quality

of care outcomes or result in the shifting of costs of providing

services to beneficiaries of a program to any other payor.

10. An approved organization shall submit reports to the commissioner

in such form and at times as may be required in order to evaluate the

operations and results of such program.

11. The commissioner, in consultation with the subcommittee, shall

enter into agreements with one or more persons, not-for-profit

corporations, or other organizations, other than a state employee,

official or agency, for the performance of a comprehensive evaluation of

the implementation and effectiveness of the regional pilot projects

authorized pursuant to this act. The evaluation shall assess factors

including, but not limited to:

(i) the overall effect of the regional pilot projects on access to and

utilization of health care services;

(ii) the impact of the regional pilot projects on the health status of

program participants;

(iii) the impact of using a negotiated special payment rate

methodology on access to and quality of inpatient and outpatient

services delivered by general hospitals and on the functioning of such

hospitals;

(iv) the impact of using alternative insurance, financing, health care

delivery and provider payment models on the costs of health care

coverage;

(v) the impact of the regional pilot projects on the bad debt and

charity care system and on other insurers, employment and health care

delivery systems in the regional pilot project location;

(vi) the feasibility and appropriateness of implementing the regional

pilot projects in other locations and on a statewide basis; and

(vii) the impact on the regional pilot projects of any adjustment of

subsidy payments or incentive payments.

An evaluation required pursuant to this section shall be submitted to

the governor and the legislature by April 1, 1995.

12. Notwithstanding any inconsistent provision of section 112 or 163

of the state finance law or any other law, at the discretion of the

commissioner without a competitive bid or request for proposal process,

contractual arrangements with approved organizations in effect in 1993

may be extended through December 31, 1999 to provide an uninterrupted

continuation of services and may be amended as may be necessary.