N.Y. Social Services Law § 367-o: Health insurance demonstration programs

§ 367-o. Health insurance demonstration programs. 1. Notwithstanding

any inconsistent provision of law, the commissioner of health is

authorized to establish one or more demonstration programs for the

purposes of providing additional knowledge and experience in mechanisms

to provide, maintain or subsidize health insurance coverage for

unemployed and underemployed health care workers.

2. Health insurance continuation demonstration. (a) The commissioner

of health is hereby authorized to establish mechanisms to improve the

process of authorizing medical assistance payment of health insurance

premiums, pursuant to paragraph (c) of subdivision one of section three

hundred sixty-seven-a of this title, on behalf of personal care and home

health care workers who reside in any city with a population of one

million or more and any county with a population of nine hundred

thousand or more if such city or county is located within the

metropolitan commuter transportation district created pursuant to

section twelve hundred sixty-two of the public authorities law, and

whose employment is irregular, episodic, or cyclical, and whose health

insurance coverage therefore is frequently disrupted. Notwithstanding

the provisions of section three hundred sixty-five of this title, the

commissioner of health shall exercise discretion to determine whether

medical assistance payment of such premiums is cost effective. If the

commissioner of health determines that the test of cost effectiveness of

insurance premiums is based on other than a case-by-case basis, no

medical assistance payment for such premiums will be made until the

commissioner of health obtains all necessary approvals under federal law

and regulation to receive federal financial participation in the costs

of such medical assistance.

(b) The commissioner of health is authorized in consultation with the

superintendent of financial services to require group health insurance

plans and employer-based group health plans to report to the department

or its designee, insofar as such reporting does not violate any

provisions of the federal Employee Retirement Income Security Act of

1974 (ERISA), at such times and in such manner as the commissioner of

health shall decide, any information needed to operate such a

demonstration project, including, but not limited to, the number of

persons in such plans who become ineligible each month for the

continuation coverage described in paragraph (a) of this subdivision. In

addition, every health maintenance organization certified under article

forty-four of the public health law and every insurer licensed by the

superintendent of financial services shall submit reports to the

superintendent and to the commissioner of health in such form and at

such times as may be required to implement the provisions of this

subdivision.

3. Rate incentive demonstration. With respect to a demonstration

program authorized by subdivision one of this section, the commissioner

of health may solicit and accept applications for participation in the

demonstration program from any employer, or group of employers, of

personal care workers or home health workers, who are employed in any

city with a population of one million or more and any county with a

population of nine hundred thousand or more if such city or county is

located within the metropolitan commuter transportation district created

pursuant to section twelve hundred sixty-two of the public authorities

law, and whose employers provide services primarily to medical

assistance recipients, if the following conditions are met:

(a) at least fifty percent of the persons receiving services from such

employers are recipients of medical assistance;

(b) the employer contributes to a group health insurance plan or

employer based group health plan on behalf of such employees; and

(c) no benefits are provided under the group health insurance plan or

employer based group health plan in excess of the benefits provided to

the majority of hospital workers in the community in which the personal

care and home health care workers are employed. The commissioner of

health is authorized to add up to fifty-eight million dollars per year

for the period January first, two thousand through December

thirty-first, two thousand two, and up to one hundred sixty-three

million dollars per year for the period January first, two thousand

three through June thirtieth, two thousand seven, to rates of payment

for qualifying personal care providers and certified home health

agencies who are approved to participate in the demonstration program.

The commissioner may modify the amounts made available for any specific

annual period so long as the total amount made available for the period

of the demonstration is not exceeded.

3-a. (a) Notwithstanding subdivision three of this section or any

other contrary provision of law and subject to the availability of

federal financial participation, the commissioner of health shall, for

periods on and after July first, two thousand seven through March

thirty-first, two thousand eight, and within amounts appropriated,

adjust rates of payments for certified home health agencies and

providers of personal care services who, (i) are located in a city with

a population of over one million persons, or in a county with a

population of over nine hundred thousand persons if such county is

located within the metropolitan commuter transportation district created

pursuant to section twelve hundred sixty-two of the public authorities

law; and (ii) provide more than fifty percent of their total annual

hours of home care services to recipients of medical assistance; and

(iii) contribute, as of July first, two thousand seven, to a group

health insurance plan or employer based group health plan on behalf of

their employees.

(b) Payments made pursuant to this subdivision to eligible providers

shall be made proportionally in the form of an add-on to rates of

payment, based on each eligible provider's most currently available

total annual hours of home care services, as reported to the department,

provided to recipients of medical assistance.

(c) Providers which have their rates of payment adjusted pursuant to

this subdivision shall use such funds solely for the purpose of

supporting health insurance coverage for their employees and are

prohibited from using such funds for any other purpose. The commissioner

of health is authorized to audit such providers for the purpose of

ensuring compliance with the provisions of this paragraph and shall

recoup any funds determined to have been used for purposes other than as

authorized by this subdivision.

4. Notwithstanding any other law, rule or regulation to the contrary,

any subscriber contract issued by an organization certified pursuant to

article forty-four of the public health law may, for purposes of

implementation of the demonstration authorized by subdivision three of

this section, be issued on an experience rated basis.

5. Between January first, two thousand and December thirty-first, two

thousand two, the state share amount for all demonstrations pursuant to

this section shall be no more than twenty-seven million dollars per

twelve month period if averaged over the term of the demonstration; and

between January first, two thousand three and June thirtieth, two

thousand seven, the state share amount for all demonstrations pursuant

to this section shall be no more than sixty-nine million dollars per

twelve month period if averaged over the term of the demonstration and

between July first, two thousand seven and March thirty-first, two

thousand eight, the state share of medical assistance payments

authorized in accordance with subdivision two of this section shall not

exceed two million eight hundred fifty thousand dollars.