N.Y. Public Health Law § 268-d: Special functions of the Marketplace related to health plan certification and qualified health plan oversight

§ 268-d. Special functions of the Marketplace related to health plan

certification and qualified health plan oversight. 1. Health plans

certified by the Marketplace shall meet the following requirements:

(a) The insurer offering the health plan:

(i) is licensed or certified by the superintendent or commissioner, in

good standing to offer health insurance coverage in this state, and

meets the requirements established by the Marketplace;

(ii) offers at least one qualified health plan and/or other or

additional health plans authorized for sale by the department of

financial services or the department in each of the silver and gold

levels as required by state law, provided, however, that the Marketplace

may require additional benefit levels to be offered by all insurers

participating in the Marketplace;

(iii) has filed with and received approval from the superintendent of

its premium rates and policy or contract forms pursuant to the insurance

law and/or this chapter;

(iv) does not charge any cancellation fees or penalties for

termination of coverage in violation of applicable law; and

(v) complies with the regulations developed by the secretary under

section 1311(c) of the federal act and such other requirements as the

Marketplace may establish.

(b) The health plan: (i) provides the essential health benefits

package described in state law or required by the Marketplace and

includes such additional benefits as are mandated by state law, except

that the health plan shall not be required to provide essential benefits

that duplicate the minimum benefits of qualified dental plans if:

(A) the Marketplace has determined that at least one qualified dental

plan or dental plan approved by the department of financial services or

the department is available to supplement the health plan's coverage;

and

(B) the insurer makes prominent disclosure at the time it offers the

health plan, in a form approved by the Marketplace, that the plan does

not provide the full range of essential pediatric benefits, and that

qualified dental plans or dental plans approved by the department of

financial services or department of health providing those benefits and

other dental benefits not covered by the plan are offered through the

Marketplace;

(ii) provides at least a bronze level of coverage as defined by state

law, unless the plan is certified as a qualified catastrophic plan, as

defined in section 1302(e) of the federal act and the insurance law, and

shall only be offered to individuals eligible for catastrophic coverage;

(iii) has cost-sharing requirements, including deductibles, which do

not exceed the limits established under section 1302(c) of the federal

act, state law and any requirements of the Marketplace;

(iv) complies with regulations promulgated by the secretary pursuant

to section 1311(c) of the federal act and applicable state law, which

include minimum standards in the areas of marketing practices, network

adequacy, essential community providers in underserved areas,

accreditation, quality improvement, uniform enrollment forms and

descriptions of coverage and information on quality measures for health

benefit plan performance;

* (v) meets standards specified and determined by the Marketplace,

provided that the standards do not conflict with or prevent the

application of federal requirements;

* NB Effective until January 1, 2028

* (v) meets standards specified and determined by the Marketplace,

provided that the standards do not conflict with or prevent the

application of federal requirements; and

* NB Effective January 1, 2028

* (vi) contracts with any national cancer institute-designated cancer

center licensed by the department within the health plan's service area

that is willing to agree to provide cancer-related inpatient, outpatient

and medical services to enrollees in all health plans offering coverage

through the Marketplace in such cancer center's service area under the

prevailing terms and conditions that the plan requires of other similar

providers to be included in the plan's provider network, provided that

such terms shall include reimbursement of such center at no less than

the fee-for-service medicaid payment rate and methodology applicable to

the center's inpatient and outpatient services; and

* NB Effective until January 1, 2028

* (vi) complies with the insurance law and this chapter requirements

applicable to health insurance issued in this state and any regulations

promulgated pursuant thereto that do not conflict with or prevent the

application of federal requirements; and

* NB Effective January 1, 2028

* (vii) complies with the insurance law and this chapter requirements

applicable to health insurance issued in this state and any regulations

promulgated pursuant thereto that do not conflict with or prevent the

application of federal requirements; and

* NB Repealed January 1, 2028

(c) The Marketplace determines that making the health plan available

through the Marketplace is in the interest of qualified individuals in

this state.

2. The Marketplace shall not exclude a health plan:

(a) on the basis that the health plan is a fee-for-service plan;

(b) through the imposition of premium price controls by the

Marketplace; or

(c) on the basis that the health plan provides treatments necessary to

prevent patients' deaths in circumstances the Marketplace determines are

inappropriate or too costly.

3. The Marketplace shall require each insurer certified or seeking

certification of a health plan as a qualified health plan or plan

approved for sale by the department of financial services or the

department to:

(a) submit a justification for any premium increase pursuant to

applicable law prior to implementation of such increase. The insurer

shall prominently post the information on its internet website. Such

rate increases shall be subject to the prior approval of the

superintendent pursuant to the insurance law;

(b)(i) make available to the public and submit to the Marketplace, the

secretary and the superintendent, accurate and timely disclosure of:

(A) claims payment policies and practices;

(B) periodic financial disclosures;

(C) data on enrollment and disenrollment;

(D) data on the number of claims that are denied;

(E) data on rating practices;

(F) information on cost-sharing and payments with respect to any

out-of-network coverage;

(G) information on enrollee and participant rights under title I of

the federal act; and

(H) other information as determined appropriate by the secretary or

otherwise required by the Marketplace;

(ii) the information shall be provided in plain language, as that term

is defined in section 1311(e)(3)(B) of the federal act and state law,

and in guidance jointly issued thereunder by the secretary and the

federal secretary of labor; and

(c) provide to individuals, in a timely manner upon the request of the

individual, the amount of cost-sharing, including deductibles,

copayments, and coinsurance, under the individual's health plan or

coverage that the individual would be responsible for paying with

respect to the furnishing of a specific item or service by a

participating provider. At a minimum, this information shall be made

available to the individual through an internet website and through

other means for individuals without access to the internet.

4. The Marketplace shall not exempt any insurer seeking certification

of a health plan, regardless of the type or size of the insurer, from

licensing or solvency requirements under the insurance law or this

chapter, and shall apply the criteria of this section in a manner that

ensures a level playing field for insurers participating in the

Marketplace.

5. (a) The provisions of this article that apply to qualified health

plans and plans approved for sale by the department of financial

services and the department also shall apply to the extent relevant to

qualified dental plans approved for sale by the department of financial

services or the department, except as modified in accordance with the

provisions of paragraphs (b) and (c) of this subdivision or otherwise

required by the Marketplace.

(b) The qualified dental plan or dental plan approved for sale by the

department of financial services and/or the department shall be limited

to dental and oral health benefits, without substantially duplicating

the benefits typically offered by health benefit plans without dental

coverage, and shall include, at a minimum, the essential pediatric

dental benefits prescribed by the secretary pursuant to section

1302(b)(1)(J) of the federal act, and such other dental benefits as the

Marketplace or secretary may specify in regulations.

(c) Insurers may jointly offer a comprehensive plan through the

Marketplace in which an insurer provides the dental benefits through a

qualified dental plan or plan approved by the department of financial

services or the department and an insurer provides the other benefits

through a qualified health plan, provided that the plans are priced

separately and also are made available for purchase separately at the

same price.