N.Y. Public Health Law § 2511: Child health insurance plan 1

§ 2511. Child health insurance plan 1. (a) The commissioner, in

consultation with the superintendent, shall establish a program to the

extent of funds available therefor through contractual arrangements with

approved organizations to provide covered health care services coverage

for eligible children. The availability of coverage for primary and

preventive health care services and inpatient health care services

coverage shall be continued pending approval of contractual arrangements

that include covered health care services coverage and implementation of

such coverage to the extent of funds available therefor.

(b) Coverage for covered health care services shall not be effective

until such time as contractual arrangements are executed pursuant to

this section for such purposes and an eligible child is enrolled in the

program.

2. In order to be eligible for a subsidy payment pursuant to

subdivision three of this section, a child shall meet the following

criteria:

(a) (i) effective January first, nineteen hundred ninety-nine, resides

in a household having a net household income at or below one hundred

ninety-two percent of the non-farm federal poverty level (as defined and

updated by the United States department of health and human services) or

the gross equivalent of such net income; and

(ii) effective July first, two thousand, resides in a household having

a gross household income at or below two hundred fifty percent of the

non-farm federal poverty level (as defined and updated by the United

States department of health and human services); and

(iii) effective September first, two thousand eight, resides in a

household having a household income at or below four hundred percent of

the non-farm federal poverty level (as defined and updated by the United

States department of health and human services);

(b) is not eligible for medical assistance, except that a child who

becomes eligible for medical assistance after becoming an eligible child

under this title, may be eligible for a subsidy payment pursuant to

subdivision three of this section as medical assistance for a period up

to three months after becoming eligible for medical assistance; and

(c) does not have health care coverage under insurance, as defined by

the commissioner, in consultation with the superintendent. The applicant

for insurance shall attest to the source and nature of the child's

health care coverage under this paragraph, if any; and

* (e) is a resident of New York state. Such residency shall be

demonstrated by adequate proof, as determined by the commissioner, of a

New York state street address. If the child has no street address, such

proof may include, but not be limited to, school records or other

documentation determined by the commissioner.

* NB Effective until January 1, 2014 or a later date to be determined

by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (e) is a resident of New York state. Such residency shall be

attested to by the applicant for insurance, provided however, the

commissioner shall require adequate proof of a New York state street

address in circumstances when there is an inconsistency with residency

information from other data sources.

* NB Effective January 1, 2014 or a later date to be determined by the

commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

(f) * (i) In order to establish income eligibility under this

subdivision at initial application, a household shall provide such

documentation specified in subparagraph (iii) of this paragraph, as

necessary and sufficient to determine a child's financial eligibility

for a subsidy payment under this title. The commissioner may verify the

accuracy of such income information provided by the household by

matching it against income information contained in databases to which

the commissioner has access, including the state's wage reporting system

pursuant to subdivision five of section one hundred seventy-one-a of the

tax law and by means of an income verification performed pursuant to a

cooperative agreement with the department of taxation and finance

pursuant to subdivision four of section one hundred seventy-one-b of the

tax law.

* NB Effective until January 1, 2014 or a later date to be determined

by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (i) In order to establish income eligibility under this subdivision

at initial application, a household shall provide the social security

numbers for each parent and legally responsible adult who is a member of

the household, subject to subparagraph (v) of this paragraph. The

commissioner shall determine eligibility based on income information

contained in databases to which the commissioner has access, including

the state's wage reporting system pursuant to subdivision five of

section one hundred seventy-one-a of the tax law and by means of an

income verification performed pursuant to a cooperative agreement with

the department of taxation and finance pursuant to subdivision four of

section one hundred seventy-one-b of the tax law. The commissioner shall

require an attestation by the household that the income information

obtained from electronic data sources is accurate. Such attestation

shall include any other household income information not obtained from

an electronic data source that is necessary to determine a child's

financial eligibility for a subsidy payment under this title. If the

attestation is reasonably compatible with information obtained from

available data sources, no further information or documentation is

required. If the attestation is not reasonably compatible with

information obtained from available data sources, documentation shall be

required as specified in subparagraph (iii) of this paragraph.

* NB Effective January 1, 2014 or a later date to be determined by the

commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

(ii) In order to establish income eligibility under this subdivision

at recertification, the commissioner may make a redetermination of

eligibility without requiring information from the individual if able to

do so based on reliable information contained in the individual's

enrollment file or other more current information contained in databases

to which the commissioner has access, including the state's wage

reporting system and by means of an income verification performed

pursuant to a cooperative agreement with the department of taxation and

finance pursuant to subdivision four of section one hundred

seventy-one-b of the tax law. The commissioner shall require an

attestation by the household that the income information contained in

the enrollment file or obtained from electronic data sources is

accurate. Such attestation shall include any other household income

information not obtained from an electronic data source that is

necessary to redetermine a child's financial eligibility for a subsidy

payment under this title. In the event that there is an inconsistency

between the income information attested to by the household and any

information obtained by the commissioner from other sources pursuant to

this subparagraph, and such inconsistency is material to the household's

eligibility for a subsidy payment under this title, the commissioner

shall require the household to provide income documentation as specified

in subparagraph (iii) of this paragraph.

* (iii) Income documentation shall include, but not be limited to, one

or more of the following for each parent and legally responsible adult

who is a member of the household and whose income is available to the

child;

(A) current annual income tax returns;

(B) paycheck stubs;

(C) written documentation of income from all employers; or

(D) written documentation of income eligibility of a child for free or

reduced breakfast or lunch through the school meal program certified by

the child's school, provided that:

(I) the commissioner may verify the accuracy of the information

provided in the same manner and way as provided for in subparagraph (ii)

of this paragraph; and

(II) such documentation may not be suitable proof of income in the

event of a material inconsistency in income after the commissioner has

performed verification pursuant to subparagraph (ii) of this paragraph;

or

(E) other documentation of income (earned or unearned) as determined

by the commissioner, provided, however, such documentation shall set

forth the source of such income.

* NB Effective until January 1, 2014 or a later date to be determined

by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (iii) If the attestation of household income required by

subparagraphs (i) and (ii) of this paragraph is not reasonably

compatible with information obtained from data sources, further

information, including documentation, shall be required. Income

documentation shall include, but not be limited to, one or more of the

following for each parent and legally responsible adult who is a member

of the household and whose income is available to the child;

(A) current annual income tax returns;

(B) paycheck stubs;

(C) written documentation of income from all employers; or

(D) written documentation of income eligibility of a child for free or

reduced breakfast or lunch through the school meal program certified by

the child's school, provided that:

(I) the commissioner may verify the accuracy of the information

provided in the same manner and way as provided for in subparagraph (ii)

of this paragraph; and

(II) such documentation may not be suitable proof of income in the

event of a material inconsistency in income after the commissioner has

performed verification pursuant to subparagraph (ii) of this paragraph;

or

(E) other documentation of income (earned or unearned) as determined

by the commissioner, provided, however, such documentation shall set

forth the source of such income.

* NB Effective January 1, 2014 or a later date to be determined by the

commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (iv) In the event a household does not provide income documentation

required by subparagraph (iii) of this paragraph within two months of

the approved organization's request, the approved organization shall

disenroll the child at the end of such two month period. Except as

provided in paragraph (c) of subdivision five-a of this section,

approved organizations shall not be obligated to repay subsidy payments

made by the state on behalf of children enrolled during this two month

period.

* NB Effective until January 1, 2014 or a later date to be determined

by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (iv) In the event a household does not provide income documentation

required by subparagraph (iii) of this paragraph within two months of

the approved organization's or state enrollment center's request,

whichever is applicable, the approved organization or state enrollment

center shall disenroll the child at the end of such two month period.

Except as provided in paragraph (c) of subdivision five-a of this

section, approved organizations shall not be obligated to repay subsidy

payments made by the state on behalf of children enrolled during this

two month period.

* NB Effective January 1, 2014 or a later date to be determined by the

commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (v) In the event a household chooses not to provide the social

security numbers required by subparagraph (ii) of this paragraph, such

household shall provide income documentation specified in subparagraph

(iii) of this paragraph as a condition of the child's enrollment.

Nothing in this paragraph shall be construed as obligating a household

to provide social security numbers of parents or legally responsible

adults as a condition of a child's enrollment or eligibility for a

subsidy payment under this title.

* NB Effective until January 1, 2014 or a later date to be determined

by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (v) In the event a household chooses not to provide the social

security numbers required by subparagraphs (i) and (ii) of this

paragraph, such household shall provide income documentation specified

in subparagraph (iii) of this paragraph as a condition of the child's

enrollment. Nothing in this paragraph shall be construed as obligating a

household to provide social security numbers of parents or legally

responsible adults as a condition of a child's enrollment or eligibility

for a subsidy payment under this title.

* NB Effective January 1, 2014 or a later date to be determined by the

commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (vi) Any income verification response by the department of taxation

and finance pursuant to subparagraphs (i) and (ii) of this paragraph

shall not be a public record and shall not be released by the

commissioner, the department of taxation and finance or an approved

organization except pursuant to this paragraph. Information disclosed

pursuant to this paragraph shall be limited to information necessary for

verification. Information so disclosed shall be kept confidential by the

party receiving such information. Such information shall be expunged

within a reasonable time to be determined by the commissioner and the

department of taxation and finance.

* NB Effective until January 1, 2014 or a later date to be determined

by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (vi) Any income verification response by the department of taxation

and finance pursuant to subparagraphs (i) and (ii) of this paragraph

shall not be a public record and shall not be released by the

commissioner, the department of taxation and finance, an approved

organization, or the state enrollment center, except pursuant to this

paragraph. Information disclosed pursuant to this paragraph shall be

limited to information necessary for verification. Information so

disclosed shall be kept confidential by the party receiving such

information. Such information shall be expunged within a reasonable time

to be determined by the commissioner and the department of taxation and

finance.

* NB Effective January 1, 2014 or a later date to be determined by the

commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (g) (i) Notwithstanding any inconsistent provision of law to the

contrary and subject to the availability of federal financial

participation under title XIX of the federal social security act, a

child under the age of nineteen shall be presumed to be eligible for

subsidy payments and temporarily enrolled for coverage under this title,

once during a twelve month period, beginning on the first day of the

enrollment period following the date that an approved organization

determines, on the basis of preliminary information, that a child's net

household income does not exceed the income level specified in title

eleven of article five of the social services law for children eligible

for medical assistance based on such child's age. The temporary

enrollment period shall continue until the earlier of the date an

eligibility determination is made pursuant to this title or title eleven

of article five of the social services law, or two months after the date

temporary enrollment begins; provided however, a temporary enrollment

period may be extended in the event an eligibility determination under

this title or title eleven of article five of the social services law is

not made within such two month period through no fault of the applicant

for insurance for medical assistance. The commissioner shall assure that

children who are enrolled pursuant to this paragraph receive the

appropriate follow-up for a determination of eligibility for benefits

under this title or title eleven of article five of the social services

law prior to the termination of the temporary enrollment period. The

commissioner shall assure that children and their families are informed

of all available enrollment sites in accordance with subdivision nine of

this section.

(ii) Effective September first two thousand seven, through March

thirty-first, two thousand fourteen temporary enrollment pursuant to

subparagraph (i) of this paragraph shall be provided only to children

who apply for recertification of coverage under this title who appear to

be eligible for medical assistance under title eleven of article five of

the social services law.

* NB Expires July 1, 2025

* (h) The commissioner may, in consultation with the superintendent,

promulgate rules and regulations necessary to prevent fraud and abuse in

eligibility determinations made by approved organizations pursuant to

this subdivision.

* NB Expires July 1, 2025

(i) Notwithstanding any inconsistent provision of law, rule or

regulation:

(i) A newborn child who meets the eligibility criteria set forth in

this subdivision or subdivision five of this section, as determined by

an approved organization or the health insurance exchange marketplace,

whichever is applicable, shall be enrolled retroactively to the first

day of the month in which the child is born, provided that the applicant

for insurance submits a completed and signed application and required

information and documentation within sixty days of the child's birth.

(ii) A newborn child shall be presumed eligible for subsidy payments

under this subdivision or eligible for coverage under subdivision five

of this section, provided that the applicant for insurance submits a

completed and signed application within sixty days of the child's birth.

Once eligibility is determined by the approved organization or the

health insurance exchange marketplace, whichever is applicable, on the

basis of preliminary information, the child shall be enrolled

retroactively to the first day of the month in which the child is born.

All other procedures and standards regarding presumptive enrollment

applicable to eligible children enrolled under this title and specified

in state contracts with approved organizations or implemented by the

health insurance exchange marketplace, whichever is applicable, shall

apply to presumptive enrollment of newborn children.

(j) Where an application for recertification of coverage under this

title contains insufficient information for a final determination of

eligibility for continued coverage, a child shall be presumed eligible

for a period not to exceed the earlier of two months beyond the

preceding period of eligibility or the date upon which a final

determination of eligibility is made based on the submission of

additional data. In the event such additional information is not

submitted within two months of the approved organization's or state

enrollment center's request, whichever is applicable, the approved

organization or state enrollment center shall disenroll the child

following the expiration of such two month period. Except as provided in

paragraph (c) of subdivision five-a of this section, approved

organizations shall not be obligated to repay subsidy payments received

on behalf of children enrolled during this two month period.

2-a. (a) An approved organization that has reasonable cause to believe

that an applicant for insurance, parent or legally responsible adult has

provided false income information may submit tax returns and any other

available income information, including, if not prohibited by federal

law for purposes of income verification, social security account

numbers, to the department as may be necessary to determine income

eligibility. The department shall promptly furnish to the department of

taxation and finance, pursuant to the agreements authorized by

subdivision five of section one hundred seventy-one-a and subdivision

four of section one hundred seventy-one-b of the tax law, the names,

address and social security account numbers, if available, of the

parents and legally responsible adults who are members of the household,

together with a request that the department of taxation and finance,

pursuant to those agreements, promptly ascertain insofar as is possible,

and from the most recent available data, whether the collective income

reported by those individuals exceeds the income eligibility level for

that household, as determined by the department in compliance with

paragraph (a) of subdivision two of this section. The department, in

consultation with the department of taxation and finance, shall

establish a methodology for comparing numerical equivalents. In

ascertaining whether a household's income exceeds the income eligibility

threshold transmitted by the department, the department of taxation and

finance shall also examine information available pursuant to section one

hundred seventy-one-a of the tax law where any of the named individuals

have failed to file a New York state income tax return for the most

recent filing year or where there is an indication, from the department

or otherwise, that the individual's income may have changed. Reliance on

such section one hundred seventy-one-a information shall be specially

indicated in the department of taxation and finance's response. This

provision shall not be construed to authorize the department of taxation

and finance to disclose any figure on any personal income tax return.

The department shall promptly inform the approved organization of the

response from the department of taxation and finance. Submission of

income information for verification shall not delay the application of

any other provision of this section to an applicant for insurance or an

enrolled child.

(b) Before an approved organization submits income information to the

department for verification with the department of taxation and finance,

it shall:

(i) provide the applicant for insurance with notification of its

intent to seek such verification;

(ii) notify the applicant for insurance of the confidentiality and

expungement provisions contained in paragraph (c) of this subdivision;

and

(iii) provide the applicant for insurance with the opportunity to

review and modify the income information.

(c) Such income information and verification response by the

department of taxation and finance shall not be a public record and

shall not be released by the department, the department of taxation and

finance or the approved organization except pursuant to this

subdivision. Information disclosed pursuant to this section shall be

limited to information necessary for verification. Information so

disclosed shall be kept confidential by the party receiving such

information. Such income information shall be expunged within a

reasonable time to be determined by the department and the department of

taxation and finance.

2-b. (a) For purposes of claiming federal financial participation

under paragraph nine of subsection (c) of section twenty-one hundred

five of the federal social security act, a household shall provide:

(i) the social security number for the applicant to be verified by the

commissioner in accordance with a process established by the social

security administration pursuant to federal law, or

(ii) documentation of citizenship and identity of the applicant

consistent with requirements under the medical assistance program, as

specified by the commissioner on the initial application.

(b) Pending receipt of the information required by subparagraph (i) of

paragraph (a) of this subdivision, an initial application shall continue

to be processed by an approved organization or enrollment facilitator

and a child shall be presumptively enrolled in the program in accordance

with procedures and timeframes currently specified in contracts.

2-c. Express lane eligibility. (a) Notwithstanding any inconsistent

provision of law, rule or regulation, the commissioner is authorized to

(i) establish standards and procedures for express lane enrollment and

renewal implemented in accordance with section 2107(e)(1)(B) of the

federal social security act, including but not limited to reliance on a

finding made by an express lane agency, as defined in section

1902(e)(13)(F) of the federal social security act, to determine whether

a child meets one or more of the eligibility criteria set forth in

subdivision two of this section; (ii) specify such standards and

procedures in the state child health plan established under title XXI of

the federal social security act and applicable contracts with approved

organizations and enrollment facilitators; and (iii) waive any

information and documentation requirements set forth in this section

necessary to implement express lane eligibility pursuant to standards

and procedures established under subparagraphs (i) and (ii) of this

paragraph; provided, however, that information and documentation

required pursuant to subdivision two-b of this section may not be

waived.

(b) Subject to federal approval, such standards and procedures shall

specify that information and documentation regarding citizenship and

immigration status collected by an express lane agency and provided to

the commissioner for the purpose of express lane eligibility may be used

to satisfy the requirements of subdivision two-b of this section.

(c) Such standards and procedures shall also include a process for

determining enrollment error rates and implementing corrective actions

as required by section 1902(e)(13)(E) of the federal social security

act.

3. Subsidy payments shall be made, pursuant to subdivision eight of

this section, to approved organizations for the purposes of subsidizing

the entire cost of coverage for eligible children meeting the criteria

of subdivision two of this section. Notwithstanding any inconsistent

provision of this subdivision, the total annual aggregate cost-sharing

with respect to all eligible children in a family under this section

shall not exceed amounts provided pursuant to applicable federal law. In

order to be eligible for a subsidy payment pursuant to this subdivision

a premium payment shall be paid for an eligible child in accordance with

the provisions of subdivision nine of section twenty-five hundred ten of

this title. Nothing herein shall preclude payment of the premium on

behalf of an eligible child on a monthly, quarterly, semi-annual or

annual basis.

4. Households shall report to the approved organization or state

enrollment center, whichever is applicable, within thirty days, any

changes in New York state residency or health care coverage under

insurance that may make a child ineligible for subsidy payments pursuant

to this section. Any individual who, with the intent to obtain benefits,

willfully misstates income or residence to establish eligibility

pursuant to subdivision two of this section or willfully fails to notify

an approved organization or state enrollment center of a change in

residence or health care coverage pursuant to this subdivision shall

repay such subsidy to the commissioner. Individuals seeking to enroll

children for coverage shall be informed that such willful misstatement

or failure to notify shall result in such liability.

4-a. Any individual who, with the intent to obtain benefits, willfully

misstates income or residence to establish eligibility pursuant to

subdivision two of this section or willfully fails to notify an approved

organization of an increase in income or change in residence pursuant to

subdivision two of this section shall repay such subsidy to the

commissioner. Individuals seeking to enroll children for coverage shall

be informed that such willful misstatement or failure to notify shall

result in such liability.

5. Notwithstanding any inconsistent provisions of subdivision two of

this section, an individual who meets the criteria of paragraphs (b) and

(c) of subdivision two of this section but not the criteria of paragraph

(a) of such subdivision may be enrolled for covered health care

services, provided however, that an approved organization shall not be

eligible to receive a subsidy payment for providing coverage to such

individuals. The cost of coverage shall be determined by the

commissioner, in consultation with the superintendent and shall be no

more than the cost of providing such coverage.

5-a. Obligations of approved organizations or the state enrollment

center. (a) An approved organization or state enrollment center,

whichever is applicable, shall have the obligation to review all

information provided pursuant to subdivision two of this section and

shall not certify or recertify a child as eligible for a subsidy payment

unless the child meets the eligibility criteria.

(b) An approved organization or state enrollment center, whichever is

applicable, shall promptly review all information relating to a

potential change in eligibility based on information provided pursuant

to subdivision four of this section. Within at least thirty days after

receipt of such information, the approved organization or state

enrollment center shall make a determination whether the child is still

eligible for a subsidy payment and shall notify the household and the

commissioner if it determines the child is not eligible for a subsidy

payment.

(c) Any approved organization which engages in a pattern and practice

of enrolling or recertifying children who are ineligible pursuant to

subdivision two of this section, as determined by the commissioner, in

consultation with the superintendent, shall be required to repay all

subsidy payments received on account of ineligible children. Improper

enrollment based upon a good faith reliance on documentation which

appears accurate on its face shall not constitute a pattern or practice.

Any such approved organization may also be removed as an approved

organization, provided however, that eligible children shall continue to

receive services until such time as the orderly transition to other

approved organizations can be effected.

6. The commissioner shall, in consultation with the superintendent,

establish guidelines for the submission of proposals by eligible

organizations for the purposes of providing covered health care services

coverage to eligible children including, but not limited to, the

following components:

(a) standards for individual enrollment including mechanisms for

presumptive eligibility and annual recertification;

(b) standards for provider enrollment;

(c) standards for scope of covered health care service benefits;

(d) standards for health care provider payment methodologies, provided

however, that levels and methods of payment shall be consistent with

those provided under similar insurance plans;

(e) standards for appropriate utilization review, quality assurance

and case management mechanisms; and

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

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

establish a program for cards issued to eligible children which can

store or access information electronically, including the identity of

the child and such other medical data and information as the

commissioner, in consultation with the superintendent, may prescribe.

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

following criteria:

(i) designate the geographic area to be served by the program, and

estimate the number of eligible participants and actual participants in

such designated area;

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

covered health care services and, when applicable, include a network of

health care providers in sufficient numbers and geographically

accessible to service program participants;

(iii) 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;

(iv) describe proposed health care provider payment methodologies;

(v) describe in detail the estimated expenses, including personnel

costs and other types of administrative expenses which will be incurred

in the development and implementation of the program;

(vi) describe the quality assurance, utilization review and case

management mechanisms to be implemented;

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

and reporting requirements of the program;

(viii) describe the benefit package to be offered by the program and

the cost of such benefit package;

(ix) describe the provisions for arranging for or offering conversion

coverage in the event of termination of coverage under this title;

(x) demonstrate financial feasibility of the program;

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

program participants who are ineligible for subsidy payments; and

(xii) include such other information as the commissioner and the

superintendent may deem appropriate.

(b) The commissioner, in consultation with the superintendent, 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 (ix) and

(xii) of paragraph (a) of this subdivision.

(c) The commissioner, in consultation with the superintendent, shall

ensure, to the extent possible, that child health insurance plan

coverage is available in all geographic areas. The commissioner may

approve more than one approved organization to serve all or part of a

geographic area.

7-a. (a) Notwithstanding any inconsistent provisions of subdivisions

one and three of section two thousand five hundred ten of this title,

subdivisions six and seven of this section, subject to paragraph (b) of

this subdivision, and section one hundred sixty-three of the state

finance law, the commissioner may contract with organizations approved

under section three hundred sixty-four-j of the social services law,

without a competitive bid or request for proposal process, to provide

covered health care services coverage for eligible children pursuant to

this title.

(b) In order to be approved pursuant to this subdivision, an

organization shall meet the criteria set forth in subdivision seven of

this section and shall comply with standards established by the

commissioner, in consultation with the superintendent, pursuant to

subdivision six of this section.

(c) Organizations approved pursuant to this subdivision shall comply

with the requirements of this title and contractual provisions

established thereunder, title XXI of the federal social security act and

any implementing federal regulations, and requirements set forth in the

state child health plan established pursuant to title XXI of the federal

social security act.

(d) Notwithstanding any inconsistent provision of section one hundred

twelve or one hundred sixty-three of the state finance law, at the

discretion of the commissioner, without a competitive bid or request for

proposal process, contractual arrangements with approved organizations,

as defined in subdivision two of section twenty-five hundred ten of this

article, in effect in two thousand seven may be extended to any period

on and after July first, two thousand seven to provide an uninterrupted

continuation of services and may be amended as deemed necessary.

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 within such funds which may be available

for the purposes of this article. (a) Subsidy payments made to approved

organizations on and after April first, two thousand five through March

thirty-first, two thousand six, shall be at amounts approved prior to

April first, two thousand five. Applications for increases to subsidy

payments submitted by approved organizations to the superintendent on or

after January first, two thousand five, shall not be considered for

approval until after March thirty-first, two thousand six. (b) Further,

subsidy payments made to approved organizations on and after April

first, two thousand seven through March thirty-first, two thousand

eight, shall be at amounts approved prior to April first, two thousand

seven. Applications for increases to subsidy payments submitted by

approved organizations to the superintendent on or after January first,

two thousand seven, shall not be considered for approval until after

March thirty-first, two thousand eight. (c) Nothing in this subdivision

shall prohibit decreases in subsidy payments in accordance with relevant

contract provisions.

(d)(i) Effective April first, two thousand nine, payment for marketing

and facilitated enrollment activities set forth in subdivision nine of

this section and included in subsidy payments made to approved

organizations providing such services pursuant to a contract with the

state shall be limited to an amount determined annually by the

commissioner.

(ii) Such subsidy payments shall be adjusted by the commissioner to

remove any costs of approved organizations in excess of the amount

determined in accordance with subparagraph (i) of this paragraph based

on cost reports submitted to the department by approved organizations.

(f) The commissioner shall adjust subsidy payments made to approved

organizations on and after April first, two thousand eleven through

March thirty-first, two thousand twelve, so that the amount of each such

payment is reduced by one and seven-tenths percent.

(g) The commissioner may increase subsidy payments made to approved

organizations that voluntarily participate in the multi-payor patient

centered medical home program to reflect additional costs associated

with enhanced payments made to certified medical homes by approved

organizations as required by article twenty-nine-AA of this chapter.

(h) Notwithstanding any inconsistent provision of this title, articles

thirty-two and forty-three of the insurance law and subsection (e) of

section eleven hundred twenty of the insurance law, for the period April

first, two thousand fourteen through March thirty-first, two thousand

fifteen, subsidy payments made to approved organizations shall be at

amounts approved prior to April first, two thousand fourteen.

(i) Notwithstanding any inconsistent provision of this title, articles

thirty-two and forty-three of the insurance law and subsection (e) of

section eleven hundred twenty of the insurance law:

(i) The commissioner shall, subject to approval of the director of the

division of the budget, develop reimbursement methodologies for

determining the amount of subsidy payments made to approved

organizations for the cost of covered health care services coverage

provided pursuant to this title for payments made on and after January

first, two thousand twenty-four.

(ii) Effective January first, two thousand twenty-three, the

commissioner shall coordinate with the superintendent of financial

services for the transition of the subsidy payment rate setting function

to the department and, in conjunction with its independent actuary,

review reimbursement methodologies developed in accordance with

subparagraph (i) of this paragraph. Notwithstanding section one hundred

sixty-three of the state finance law, the commissioner may select and

contract with the independent actuary selected pursuant to subdivision

eighteen of section three hundred sixty-four-j of the social services

law, without a competitive bid or request for proposal process. Such

independent actuary shall review and make recommendations concerning

appropriate actuarial assumptions relevant to the establishment of

reimbursement methodologies, including but not limited to the adequacy

of subsidy payment amounts in relation to the population to be served

adjusted for case mix, the scope of services approved organizations must

provide, the utilization of such services and the network of providers

required to meet state standards.

9. The commissioner shall, within amounts available therefor, contract

with community-based and other marketing organizations for purposes of

public education, outreach, and recruitment of eligible children,

including the distribution of applications and information regarding

enrollment. In awarding such contracts, the commissioner shall consider

the marketing, outreach and recruitment efforts of approved

organizations, and the extent to which such organizations are able to

effectively target efforts in geographic regions where the proportion of

eligible children enrolled under this title are lower than in other

geographic regions of the state. Community-based organizations shall

include, but not be limited to: day care centers, schools,

community-based diagnostic and treatment centers, and hospitals.

10. Notwithstanding any other law or agreement to the contrary, and

except in the case of a child or children who also becomes eligible for

medical assistance, benefits under this title shall be considered

secondary to any other plan of insurance or benefit program, except the

children and youth with special health care needs support services

program and the early intervention program, under which an eligible

child may have coverage.

11. (a) An approved organization shall submit required reports and

information to the commissioner in such form and at times, at least

annually, as may be required by the commissioner and specified in

contracts and official department of health administrative guidance, in

order to evaluate the operations and results of the program and quality

of care being provided by such organizations. Such reports and

information shall include, but not be limited to, enrollee demographics

(applicable only until the state enrollment center is implemented),

program utilization and expense, patient care outcomes and patient

specific medical information, including encounter data maintained by an

approved organization for purposes of quality assurance and oversight.

Any information or data collected pursuant to this paragraph shall be

kept confidential in accordance with Title XXI of the federal social

security act or any other applicable state or federal law.

(b) In the event an approved organization fails to submit any required

report and information, as specified in contracts and official

department of health administrative guidance, on or before the due date

specified by the commissioner, the commissioner may reduce the approved

organization's subsidy payments by up to a total of two percent each

month for a period beginning on the first day of the calendar month

following the original due date of the required report and information

and continuing until the last day of the calendar month in which the

required report and information are submitted; provided however, an

approved organization shall not be subject to the percentage reduction

under the following conditions: (i) for any new report for which such

organization did not have reasonable notice which shall be at least

sixty days notice of its requirement, data and submission

specifications, and due date by certified mail to the approved

organization's chief financial officer; or (ii) for any report, upon a

finding by the commissioner that such report was not submitted on a

timely basis for good cause, which may include, but not be limited to,

additional time required to modify or add to computer data systems.

12. The commissioner shall, in consultation with the superintendent,

establish procedures to coordinate the child health insurance plan with

the medical assistance program, including but not limited to, procedures

to maximize enrollment of eligible children under those programs by

identification and transfer of children who are eligible or who become

eligible to receive medical assistance and procedures to facilitate

changes in enrollment status for children who are ineligible for

subsidies under this section and for children who are no longer eligible

for medical assistance in order to facilitate and ensure continuity of

coverage. The commissioner shall review, on an annual basis, the

eligibility verification and recertification procedures of approved

organizations under this title to insure the appropriate enrollment of

children. Such review shall include, but not be limited to, an audit of

a statistically representative sample of cases from among all approved

organizations and shall be applicable to any period during which an

approved organization's responsibilities include determining

eligibility. In the event such review and audit reveals cases which do

not meet the eligibility criteria for coverage set forth in this

section, that information shall be forwarded to the approved

organization and the commissioner for appropriate action.

12-a. The commissioner shall establish procedures to audit approved

organizations for compliance with the requirements of this title,

including the requirements of subdivision twelve of this section,

contractual provisions established thereunder and advisory memoranda

issued by the commissioner, title XXI of the federal social security act

and any implementing federal regulations, and requirements set forth in

the state child health plan established pursuant to title XXI of the

federal social security act. Approved organizations shall comply with

such procedures and make available any data necessary to perform such

audits. Audit procedures shall include, but not be limited to, the

following:

(a) standards and procedures for a preliminary audit to be conducted

on no more than an annual basis;

(b) standards and procedures for the submission of a plan of

correction by an approved organization, including time periods allowed

to implement such plan of correction;

(c) standards and procedures for a second audit, including an exit

conference which provides an approved organization the opportunity to

rebut the composition of the audit sample as representative prior to

recovery of subsidy payments and the imposition of penalties;

(d) standards and procedures for recovery of subsidy payments made for

ineligible children, which, notwithstanding any inconsistent provisions

of this title, may include recoveries based on extrapolated findings

from a statistically representative sample of cases which shall be

actuarially based and consistent with accepted auditing standards; and

(e) standards and procedures for the imposition of penalties for

substantial noncompliance, which may include, but not be limited to,

financial penalties in addition to penalties set forth in section twelve

of this chapter and consistent with applicable federal standards, as

specified in contracts, and contract termination; provided however

(f) audit standards and procedures established pursuant to this

section, including penalties, shall be applicable to eligibility

determinations made by approved organizations only for periods during

which an approved organization's responsibilities include making such

eligibility determinations.

14. The commissioner, in consultation with the superintendent, 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 child health insurance

program. Notwithstanding any inconsistent provision of law, the

commissioner may allocate and distribute from funds otherwise available

for distribution for purposes of this title an amount not to exceed five

hundred thousand dollars for the costs of such evaluation. The

evaluation shall include, but not be limited to:

(a) the overall effect of the child health insurance program on access

to, utilization and quality of primary and preventive health care

services, including, but not limited to, patterns of service

utilization, geographic availability of service providers, possible

reductions in uncompensated care as a result of the program, and

enrollee satisfaction with program administration, services and quality;

(b) the impact of the child health insurance program on the health

status of program participants, including the comparative impact on

families that have a child enrolled in the program and other children

that are not eligible and do not have coverage;

(c) the effect of the child health insurance program on emergency room

utilization, including the effectiveness of preventing inappropriate

utilization;

(d) the geographic accessibility of the child health insurance

program, including the availability and accessibility of service

providers, premium levels and premium increases;

(e) the effect of community-based and statewide outreach education

efforts;

(f) the results of a statistically valid sampling of cases verifying

certification and recertification of eligibility for subsidy payments

under this title including but not limited to data on failure by

approved organizations to adequately verify enrollee eligibility;

(g) any recommendations for programmatic changes to improve the child

health insurance program based on program evaluation and enrollee

satisfaction data; and

(h) a cost and patient outcome comparison of indemnity plans and

managed care plans offered under this program.

A preliminary evaluation shall be submitted to the governor and the

legislature by April first, nineteen hundred ninety-five and a further

evaluation shall be submitted by January first, nineteen hundred

ninety-six.

14-a. The commissioner shall enter into an agreement with one or more

persons, not-for-profit corporations, or other organizations, other than

a state employee, official or agency, for comprehensive research

concerning the health care coverage of children in New York state. The

organization conducting the research shall, at least annually, issue a

report of its findings to the governor and the legislature. The research

shall include, but not be limited to:

(a) a survey of the uninsured in the state;

(b) on-going comprehensive studies of the characteristics of uninsured

children and their families, including demographic characteristics, and

reasons such children and families are uninsured;

(c) the collection and dissemination of data and other relevant

information relating to the health care coverage of children and their

families; and

(d) a review of such factors relating to the uninsured in New York

state as the commissioner, in consultation with the superintendent,

shall require.

15. Notwithstanding any inconsistent provision of section one hundred

twelve or one hundred sixty-three of the state finance law or any other

law, at the discretion of the commissioner without a competitive bid or

request for proposal process:

(a) contractual arrangements with approved organizations to provide

primary and preventive health care services coverage for eligible

children, or with organizations for purposes of public education,

outreach and recruitment of eligible children, in effect in nineteen

hundred ninety-three may be extended to provide for primary and

preventive health care services coverage for eligible children or public

education, outreach and recruitment of eligible children in nineteen

hundred ninety-four and nineteen hundred ninety-five and those

contractual arrangements with approved organizations to provide primary

and preventive health care services coverage for eligible children in

effect for nineteen hundred ninety-five may be extended through June

thirtieth, nineteen hundred ninety-six to provide an uninterrupted

continuation of services and additional time for program evaluation and

may be amended as may be necessary, provided, however, that the

commissioner shall periodically review the process of ensuring adequate

participation of approved organizations under this section; and

(b) contractual arrangements with approved organizations to provide

primary and preventive health care services coverage for eligible

children, or with organizations for purposes of public education,

outreach and recruitment of eligible children in effect in the period

January first, nineteen hundred ninety-six through June thirtieth,

nineteen hundred ninety-six may be extended for public education,

outreach and recruitment of eligible children through December

thirty-first, nineteen hundred ninety-six and to provide for primary and

preventive health care services coverage for eligible children through

such periods for which such coverage continues to apply prior to the

addition of coverage for inpatient health care services to provide an

uninterrupted continuation of services and may be amended as may be

necessary.

* 16. The commissioner and the commissioner of social services shall

jointly develop a simplified application form for coverage under this

title, the medical assistance program and the federal women, infants and

children program, and shall also develop appropriate verification and

sampling procedures for the child health insurance plan in order to

facilitate the appropriate enrollment of eligible children into the

child health insurance plan, the medical assistance program, and the

women, infants and children program. Nothing in this subdivision shall

be construed to require that eligibility documentation requirements for

the services under this title shall apply to the medical assistance

program, nor shall this subdivision be construed to preclude eligibility

for any person pending the development of that application. Such

application shall be available for use by local social services

districts and approved organizations under this title by June thirtieth,

nineteen hundred ninety-four.

* NB Expired July 1, 2007

16-a. The commissioner shall develop a simplified recertification form

for use by approved organizations in renewing coverage for eligible

children under this title. The form shall include requests only for such

information that is: (i) reasonably necessary to determine continued

eligibility for coverage under this title; and (ii) subject to change

since the date of the household's initial application.

17. The commissioner, in consultation with the superintendent, is

authorized to establish and operate a child health information service

which shall utilize advanced telecommunications technologies to meet the

health information and support needs of children, parents and medical

professionals, which shall include, but not be limited to, treatment

guidelines for children, treatment protocols, research articles and

standards for the care of children from birth through eighteen years of

age. Such information shall not constitute the practice of medicine, as

defined in article one hundred thirty-one of the education law.

18. Premium Assistance Program. (a) The commissioner shall establish a

premium assistance program for the purchase of family coverage under a

group health plan or health insurance coverage that includes coverage of

an eligible child, as defined in subdivision four of section twenty-five

hundred ten of this article, contingent upon:

(i) a determination by the commissioner that the purchase of family

coverage under this subdivision is cost effective relative to the amount

the state would pay to obtain coverage under this title solely for the

eligible child or children; and

(ii) the availability of federal financial participation in accordance

with a waiver application submitted by the commissioner and approved by

the secretary of the department of health and human services.

(b) The commissioner shall establish and specify standards for the

implementation of the premium assistance program in the federal waiver

application, including, but not limited to, the following:

(i) standards for eligibility of children and families for and

enrollment in the premium assistance program which shall include, at a

minimum, the eligibility criteria set forth in subdivision two of this

section; provided that:

(A) participation in the program for a child who resides in a

household having a household income at or below two hundred fifty

percent of the non-farm federal poverty level (as defined and updated by

the United States department of health and human services) shall be

voluntary and an eligible child may disenroll from the premium

assistance program at any time and enroll in individual coverage under

this title; and

(B) participation in the program for a child who resides in a

household having a household income between two hundred fifty-one and

four hundred percent of the non-farm federal poverty level (as defined

and updated by the United States department of health and human

services) and meets certain eligibility criteria shall be mandatory. A

child in this income group who meets the criteria for enrollment in the

premium assistance program shall not be eligible for individual coverage

under this title;

(ii) standards for required levels of employer contributions toward

the cost of premiums for family coverage;

(iii) standards for the level of state payment toward the cost of

premiums for family coverage;

(iv) standards for the scope and level of benefits to be provided in

the premium assistance program;

(v) standards for data collection including, but not limited to, data

regarding the substitution of health insurance coverage that would be

provided to eligible children in the absence of family coverage

purchased pursuant to this subdivision; and

(vi) any other standards deemed necessary by the commissioner to

implement the premium assistance program.

(c) The state share of the cost of the premium assistance program, if

implemented, shall be funded within amounts appropriated for the purpose

of providing healthcare coverage for uninsured and underinsured children

pursuant to this title.

19. Claims submitted to an approved organization for payment for

medical care, services, or supplies furnished by an out-of-network

health care provider must be submitted within fifteen months of the date

the medical care, services, or supplies were furnished to an eligible

person to be valid and enforceable against the approved organization. If

a claim by an out-of-network health care provider is not submitted

within fifteen months of the date that the medical care, services or

supplies were furnished and the claim is subsequently denied by the

approved organization for that reason, such out-of-network health care

provider shall not seek payment for such medical care, services or

supplies from the enrollee. This deadline for claims submission shall

not apply where the claims submission is warranted to address findings

or recommendations identified in a state or federal audit except where

such audit also indicates that an inappropriate provider payment was

solely the fault of the out-of-network health care provider.

20. For approved organizations with negotiated rates of payment for

inpatient hospital services under contracts in effect on April first,

two thousand eight, that have a payment rate methodology for such

inpatient hospital services that utilizes rates calculated by the

department of health pursuant to paragraph (a) or (a-2) of subdivision

one of section twenty-eight hundred seven-c of the public health law for

patients under the medical assistance program, such rate shall not

include adjustments pursuant to subdivision thirty-three of section

twenty-eight hundred seven-c of this chapter for contract periods prior

to January first, two thousand ten.

21. The commissioner may make any necessary amendments to a contract

pursuant to this section with an approved organization, as defined in

subdivision two of section twenty-five hundred ten of this title, to

allow such approved organization to participate as a qualified health

plan in a state health benefit exchange established pursuant to the

federal Patient Protection and Affordable Care Act (P.L. 111-148), as

amended by the federal Health Care and Education Reconciliation Act of

2010 (P.L. 111-152).

22. Notwithstanding the provisions of this title and effective on and

after January first, two thousand twenty-three, the consultative,

review, and approval functions of the superintendent of financial

services related to administration of the child health insurance plan

are no longer applicable and references to those functions in this title

shall be null and void. The child health insurance plan set forth in

this title shall be administered solely by the commissioner. All child

health insurance plan policies reviewed and approved by the

superintendent of financial services in accordance with section eleven

hundred twenty of the insurance law shall remain in effect until the

commissioner establishes a process to review and approve member

handbooks in accordance with the requirements of Title XXI of the

federal social security act and implementing regulations, and such

member handbooks are issued by approved organizations to enrollees in

place of child health insurance plan policies which were subject to

review under section eleven hundred twenty of the insurance law.