N.Y. Public Health Law § 268-c: Functions of the Marketplace

§ 268-c. Functions of the Marketplace. The Marketplace shall:

1. (a) Perform eligibility determinations for federal and state

insurance affordability programs including medical assistance in

accordance with section three hundred sixty-six of the social services

law, child health plus in accordance with section twenty-five hundred

eleven of this chapter, the basic health program in accordance with

section three hundred sixty-nine-gg of the social services law, the 1332

state innovation program in accordance with section three hundred

sixty-nine-ii of the social services law, premium tax credits and

cost-sharing reductions and qualified health plans in accordance with

applicable law and other health insurance programs as determined by the

commissioner;

(b) certify and make available to qualified individuals, qualified

health plans, including dental plans, certified by the Marketplace

pursuant to applicable law, provided that coverage under such plans

shall not become effective prior to certification by the Marketplace;

and

(c) certify and/or make available to eligible individuals, health

plans certified by the Marketplace pursuant to applicable law, and/or

participating in an insurance affordability program pursuant to

applicable law, provided that coverage under such plans shall not become

effective prior to certification by the Marketplace, and/or approval by

the commissioner.

2. Assign an actuarial value to each Marketplace certified plan

offered through the Marketplace in accordance with the criteria

developed by the secretary pursuant to federal law or the superintendent

pursuant to the insurance law and/or requirements developed by the

Marketplace, and determine each health plan's level of coverage in

accordance with regulations issued by the secretary pursuant to federal

law or the superintendent pursuant to the insurance law.

3. Utilize a standardized format for presenting health benefit options

in the Marketplace, including the use of the uniform outline of coverage

established under section 2715 of the federal public health service act

or the insurance law.

4. Standardize the benefits available through the Marketplace at each

level of coverage defined by the superintendent in the insurance law.

5. Maintain enrollment periods in the best interest of qualified

individuals consistent with federal and state law.

6. Implement procedures for the certification, recertification and

decertification of health plans as qualified health plans or health

plans approved for sale by the department of financial services or

department of health and certified by the Marketplace, consistent with

guidelines developed by the secretary pursuant to section 1311(c) of the

federal act and requirements developed by the Marketplace.

7. Contract for health care coverage offered to qualified individuals

through the Marketplace, and in doing so shall seek to provide health

care coverage choices that offer the optimal combination of choice,

value, quality, and service.

8. Contract for health care coverage offered to certain eligible

individuals through the Marketplace, pursuant to health insurance

programs as determined by the commissioner, and in doing so shall seek

to provide health care coverage choices that offer the optimal

combination of choice, value, quality, and service;

9. Provide the minimum requirements an insurer shall meet to

participate in the Marketplace, in the best interest of qualified

individuals or eligible individuals;

10. Require qualified health plans and/or other health plans certified

by the Marketplace to offer those benefits determined to be essential

health benefits pursuant to state law or as required by the Marketplace.

11. Ensure that insurers offering health plans through the Marketplace

do not charge an individual enrollee a fee or penalty for termination of

coverage.

12. Provide for the operation of a toll-free telephone hotline to

respond to requests for assistance.

13. Maintain an internet website through which enrollees and

prospective enrollees of qualified health plans and health plans

certified by the Marketplace may obtain standardized comparative

information on such plans and insurance affordability programs.

14. Make available by electronic means a calculator to determine the

actual cost of coverage after the application of any premium tax credit

under section 36B of the Internal Revenue Code of 1986 or applicable

state law and any cost-sharing reduction under federal or applicable

state law.

15. Operate a program under which the Marketplace awards grants to

entities to serve as navigators in accordance with applicable federal

law and regulations adopted thereunder, and/or a program under which the

Marketplace awards grants to entities to provide community based

enrollment assistance in accordance with requirements developed by the

Marketplace; and/or a program under which the Marketplace certifies New

York state licensed producers to provide assistance to eligible

individuals and/or small employers pursuant to federal or state law.

16. In accordance with applicable federal and state law, inform

individuals of eligibility requirements for the Medicaid program under

title XIX of the social security act and the social services law, the

children's health insurance program (CHIP) under title XXI of the social

security act and this chapter, the basic health program under section

three hundred sixty-nine-gg of the social services law, the 1332 state

innovation program in accordance with section three hundred

sixty-nine-ii of the social services law, or any applicable state or

local public health insurance program and if, through screening of the

application by the Marketplace, the Marketplace determines that such

individuals are eligible for any such program, enroll such individuals

in such program.

17. Grant a certification that an individual is exempt from the

requirement to maintain minimum essential coverage pursuant to federal

or state law and from any penalties imposed by such requirements

because:

(a) there is no affordable health plan available covering the

individual, as defined by applicable law; or

(b) the individual meets the requirements for any other such exemption

from the requirement to maintain minimum essential coverage or to pay

the penalty pursuant to applicable federal or state law.

18. Operate a small business health options program ("SHOP") pursuant

to section 1311 of the federal act and applicable state law, through

which eligible small employers may select marketplace-certified

qualified health plans offered in the small group market, and through

which eligible small employers may receive assistance in qualifying for

small business tax credits available pursuant to federal and state law.

19. Enter into agreements as necessary with federal and state agencies

and other state Marketplaces to carry out its responsibilities under

this title, provided such agreements include adequate protections with

respect to the confidentiality of any information to be shared and

comply with all state and federal laws and regulations.

20. Perform duties required by the secretary, the secretary of the

United States department of the treasury or the commissioner related to

determining eligibility for premium tax credits or reduced cost-sharing

under applicable federal or state law.

21. Meet program integrity requirements under applicable law,

including keeping an accurate accounting of receipts and expenditures

and providing reports to the secretary regarding Marketplace related

activities in accordance with applicable law.

22. Submit information provided by Marketplace applicants for

verification as required by section 1411(c) of the federal act and

applicable state law.

23. Establish rules and regulations that do not conflict with or

prevent the application of regulations promulgated by the secretary.

24. Determine eligibility, provide notices, and provide opportunities

for appeal and redetermination in accordance with the requirements of

federal and state law.

25. The commissioner is authorized to submit the appropriate waiver

applications to the United States secretary of health and human services

and/or the department of the treasury to waive any applicable provisions

of the Patient Protection and Affordable Care Act, Pub. L. 111-148 as

amended, or successor provisions, as provided for by 42 U.S.C. 18052,

and any other waivers necessary to achieve the purposes of high quality,

affordable coverage through NY State of Health, the official health plan

marketplace. The commissioner shall implement the state plans of any

such waiver in a manner consistent with applicable state and federal

laws, as authorized by the secretary of health and human services and/or

the secretary of the treasury pursuant to 42 U.S.C. 18052. Copies of

such original waiver applications and amendments thereto shall be

provided to the chair of the senate finance committee, the chair of the

assembly ways and means committee and the chairs of the senate and

assembly health committees simultaneously with their submission to the

federal government.

* 26. Subject to federal approval if required, the use of state funds

and the availability of funds in the 1332 state innovation program fund

established pursuant to section ninety-eight-d of the state finance law,

the commissioner shall have the authority to establish a program to

provide subsidies for the payment of premium or cost sharing or both to

assist individuals who are eligible to purchase qualified health plans

through the marketplace, or take such other action as appropriate to

reduce or eliminate qualified health plan premiums or cost-sharing or

both.

* NB Effective upon the commissioner of health obtaining and

maintaining certain approvals (see chapter 57 of 2024 Pt. J § 10)