N.Y. Social Services Law § 369-gg: Basic health program

§ 369-gg. Basic health program. 1. Definitions. For purposes of this

section:

(a) "Eligible organization" means an insurer licensed pursuant to

article thirty-two or forty-two of the insurance law, a corporation or

an organization under article forty-three of the insurance law, or an

organization certified under article forty-four of the public health

law, including providers certified under section forty-four hundred

three-e of the public health law;

(b) "Approved organization" means an eligible organization approved by

the commissioner to underwrite a basic health insurance plan pursuant to

this title;

* (c) "Health care services" means (i) the services and supplies as

defined by the commissioner in consultation with the superintendent of

financial services, and shall be consistent with and subject to the

essential health benefits as defined by the commissioner in accordance

with the provisions of the patient protection and affordable care act

(P.L. 111-148) and consistent with the benefits provided by the

reference plan selected by the commissioner for the purposes of defining

such benefits, and shall include coverage of and access to the services

of any national cancer institute-designated cancer center licensed by

the department of health within the service area of the approved

organization that is willing to agree to provide cancer-related

inpatient, outpatient and medical services to all enrollees in approved

organizations' plans in such cancer center's service area under the

prevailing terms and conditions that the approved organization requires

of other similar providers to be included in the approved organization's

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 (ii) dental and vision services as defined by the

commissioner;

* NB Effective until January 1, 2031

* (c) "Health care services" means (i) the services and supplies as

defined by the commissioner in consultation with the superintendent of

financial services, and shall be consistent with and subject to the

essential health benefits as defined by the commissioner in accordance

with the provisions of the patient protection and affordable care act

(P.L. 111-148) and consistent with the benefits provided by the

reference plan selected by the commissioner for the purposes of defining

such benefits, and shall include coverage of and access to the services

of any national cancer institute-designated cancer center licensed by

the department of health within the service area of the approved

organization that is willing to agree to provide cancer-related

inpatient, outpatient and medical services to all enrollees in approved

organizations' plans in such cancer center's service area under the

prevailing terms and conditions that the approved organization requires

of other similar providers to be included in the approved organization's

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; (ii) dental and vision services as defined by the

commissioner; and (iii) as defined by the commissioner and subject to

federal approval, certain services and supports provided to enrollees

eligible pursuant to subparagraph one of paragraph (g) of subdivision

one of section three hundred sixty-six of this article who have

functional limitations and/or chronic illnesses that have the primary

purpose of supporting the ability of the enrollee to live or work in the

setting of their choice, which may include the individual's home, a

worksite, or a provider-owned or controlled residential setting;

* NB Effective January 1, 2031

(d) "Qualified health plan" means a health plan that meets the

criteria for certification described in § 1311(c) of the Patient

Protection and Affordable Care Act (P.L. 111-148), and is offered to

individuals through the health insurance exchange marketplace; and

* (e) "Basic health insurance plan" means a standard health plan

providing health care services, separate and apart from qualified health

plans, that is issued by an approved organization and certified in

accordance with this section.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

* (e) "Basic health insurance plan" means a standard health plan,

separate and apart from qualified health plans, that is issued by an

approved organization and certified in accordance with this section.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

2. Authorization. If it is in the financial interest of the state to

do so, the commissioner of health is authorized, with the approval of

the director of the budget, to establish a basic health program. The

commissioner's authority pursuant to this section is contingent upon

obtaining and maintaining all necessary approvals from the secretary of

health and human services to offer a basic health program in accordance

with 42 U.S.C. 18051. The commissioner may take any and all actions

necessary to obtain such approvals. Notwithstanding the foregoing,

within ninety days of the effective date of the chapter of the laws of

two thousand fifteen which amended this subdivision the commissioner

shall submit a report to the temporary president of the senate and the

speaker of the assembly detailing a contingency plan in the event

eligibility rules or regulations are modified or repealed; or in the

event federal payment is reduced from ninety five percent of the premium

tax credits and cost-sharing reductions pursuant to the patient

protection and affordable care act (P.L. 111-148). The contingency plan

shall be implemented within ninety days of the above stated events or

the time period specified in federal law.

3. Eligibility. A person is eligible to receive coverage for health

care services pursuant to this title if he or she:

(a) resides in New York state and is under sixty-five years of age;

(b) is not eligible for medical assistance under title eleven of this

article or for the child health insurance plan described in title one-A

of article twenty-five of the public health law;

(c) is not eligible for minimum essential coverage, as defined in

section 5000A(f) of the Internal Revenue Service Code of 1986, or is

eligible for an employer-sponsored plan that is not affordable, in

accordance with section 5000A of such code; and

* (d) (i) except as provided by subparagraph (ii) of this paragraph,

has household income at or below two hundred percent of the federal

poverty line defined and annually revised by the United States

department of health and human services for a household of the same

size; and has household income that exceeds one hundred thirty-three

percent of the federal poverty line defined and annually revised by the

United States department of health and human services for a household of

the same size; however, MAGI eligible noncitizens lawfully present in

the United States with household incomes at or below one hundred

thirty-three percent of the federal poverty line shall be eligible to

receive coverage for health care services pursuant to the provisions of

this title if such noncitizen would be ineligible for medical assistance

under title eleven of this article due to their immigration status;

(ii) subject to federal approval and the use of state funds, unless

the commissioner may use funds under subdivision seven of this section,

has household income at or below two hundred fifty percent of the

federal poverty line defined and annually revised by the United States

department of health and human services for a household of the same

size; and has household income that exceeds one hundred thirty-three

percent of the federal poverty line defined and annually revised by the

United States department of health and human services for a household of

the same size; however, MAGI eligible aliens lawfully present in the

United States with household incomes at or below one hundred

thirty-three percent of the federal poverty line shall be eligible to

receive coverage for health care services pursuant to the provisions of

this title if such alien would be ineligible for medical assistance

under title eleven of this article due to their immigration status;

(iii) subject to federal approval if required and the use of state

funds, unless the commissioner may use funds under subdivision seven of

this section, a pregnant individual who is eligible for and receiving

coverage for health care services pursuant to this title is eligible to

continue to receive health care services pursuant to this title during

the pregnancy and for a period of one year following the end of the

pregnancy without regard to any change in the income of the household

that includes the pregnant individual, even if such change would render

the pregnant individual ineligible to receive health care services

pursuant to this title;

(iv) subject to federal approval, a child born to an individual

eligible for and receiving coverage for health care services pursuant to

this title who would be eligible for coverage pursuant to subparagraphs

(2) or (4) of paragraph (b) of subdivision 1 of section three hundred

and sixty-six of the social services law shall be deemed to have applied

for medical assistance and to have been found eligible for such

assistance on the date of such birth and to remain eligible for such

assistance for a period of one year.

An applicant who fails to make an applicable premium payment, if any,

shall lose eligibility to receive coverage for health care services in

accordance with time frames and procedures determined by the

commissioner.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

* (d) (i) except as provided by subparagraph (ii) of this paragraph,

has household income at or below two hundred percent of the federal

poverty line defined and annually revised by the United States

department of health and human services for a household of the same

size; and has household income that exceeds one hundred thirty-three

percent of the federal poverty line defined and annually revised by the

United States department of health and human services for a household of

the same size; however, MAGI eligible noncitizens lawfully present in

the United States with household incomes at or below one hundred

thirty-three percent of the federal poverty line shall be eligible to

receive coverage for health care services pursuant to the provisions of

this title if such noncitizen would be ineligible for medical assistance

under title eleven of this article due to their immigration status;

(ii) subject to federal approval and the use of state funds, unless

the commissioner may use funds under subdivision seven of this section,

has household income at or below two hundred fifty percent of the

federal poverty line defined and annually revised by the United States

department of health and human services for a household of the same

size; and has household income that exceeds one hundred thirty-three

percent of the federal poverty line defined and annually revised by the

United States department of health and human services for a household of

the same size; however, MAGI eligible aliens lawfully present in the

United States with household incomes at or below one hundred

thirty-three percent of the federal poverty line shall be eligible to

receive coverage for health care services pursuant to the provisions of

this title if such alien would be ineligible for medical assistance

under title eleven of this article due to their immigration status;

(iii) subject to federal approval if required and the use of state

funds, unless the commissioner may use funds under subdivision seven of

this section, a pregnant individual who is eligible for and receiving

coverage for health care services pursuant to this title is eligible to

continue to receive health care services pursuant to this title during

the pregnancy and for a period of one year following the end of the

pregnancy without regard to any change in the income of the household

that includes the pregnant individual, even if such change would render

the pregnant individual ineligible to receive health care services

pursuant to this title;

(iv) subject to federal approval, a child born to an individual

eligible for and receiving coverage for health care services pursuant to

this title who would be eligible for coverage pursuant to subparagraphs

(2) or (4) of paragraph (b) of subdivision 1 of section three hundred

and sixty-six of the social services law shall be deemed to have applied

for medical assistance and to have been found eligible for such

assistance on the date of such birth and to remain eligible for such

assistance for a period of one year.

An applicant who fails to make an applicable premium payment shall

lose eligibility to receive coverage for health care services in

accordance with time frames and procedures determined by the

commissioner.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

4. Enrollment. (a) Subject to federal approval, the commissioner is

authorized to establish an application and enrollment procedure for

prospective enrollees. Such procedure shall include a verification

system for applicants, which shall be consistent with 42 USC § 1320b-7.

(b) Such procedure shall allow for continuous enrollment for enrollees

to the basic health program where an individual may apply and enroll for

coverage at any point.

(c) Upon an applicant's enrollment in a basic health insurance plan,

coverage for health care services pursuant to the provisions of this

title shall be prospective. Coverage shall begin in a manner consistent

with the requirements for qualified health plans offered through the

health insurance exchange marketplace, as delineated in federal

regulation at 42 CFR 155.420(b)(1) or any successor regulation thereof.

(d) A person who has enrolled for coverage pursuant to this title, and

who loses eligibility to enroll in the basic health program for a reason

other than citizenship status, lack of state residence, failure to

provide a valid social security number, providing inaccurate information

that would affect eligibility when requesting or renewing health

coverage pursuant to this title, or failure to make an applicable

premium payment, before the end of a twelve month period beginning on

the effective date of the person's initial eligibility for coverage, or

before the end of a twelve month period beginning on the date of any

subsequent determination of eligibility, shall have his or her

eligibility for coverage continued until the end of such twelve month

period, provided that the state receives federal approval for using

funds from the basic health program trust fund, established under

section 97-oooo of the state finance law, for the costs associated with

such assistance.

* 5. Premiums and cost sharing. (a) Subject to federal approval, the

commissioner shall establish premium payments enrollees shall pay to

approved organizations for coverage of health care services pursuant to

this title. No payment is required for individuals with a household

income at or below two hundred percent of the federal poverty line

defined and annually revised by the United States department of health

and human services for a household of the same size.

(b) The commissioner shall establish cost sharing obligations for

enrollees, subject to federal approval. There shall be no cost-sharing

obligations for enrollees for dental and vision services as defined in

subparagraph (ii) of paragraph (c) of subdivision one of this section;

services and supports as defined in subparagraph (iii) of paragraph (c)

of subdivision one of this section; and health care services authorized

under subparagraphs (iii) and (iv) of paragraph (d) of subdivision three

of this section.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

* 5. Premiums and cost sharing. (a) Subject to federal approval, the

commissioner shall establish premium payments enrollees shall pay to

approved organizations for coverage of health care services pursuant to

this title. Such premium payments shall be established in the following

manner:

(i) up to twenty dollars monthly for an individual with a household

income above one hundred and fifty percent of the federal poverty line

but at or below two hundred percent of the federal poverty line defined

and annually revised by the United States department of health and human

services for a household of the same size; and

(ii) no payment is required for individuals with a household income at

or below one hundred and fifty percent of the federal poverty line

defined and annually revised by the United States department of health

and human services for a household of the same size.

(b) The commissioner shall establish cost sharing obligations for

enrollees, subject to federal approval. There shall be no cost-sharing

obligations for services and supports as defined in subparagraph (iii)

of paragraph (c) of subdivision one of this section; and health care

services authorized under subparagraphs (iii) and (iv) of paragraph (d)

of subdivision three of this section.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

6. Rates of payment. (a) The commissioner shall select the contract

with an independent actuary to study and recommend appropriate

reimbursement methodologies for the cost of health care service coverage

pursuant to this title. 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 rates of payment in relation to the

population to be served adjusted for case mix, the scope of health care

services approved organizations must provide, the utilization of such

services and the network of providers required to meet state standards.

(b) Upon consultation with the independent actuary and entities

representing approved organizations, the commissioner shall develop

reimbursement methodologies and fee schedules for determining rates of

payment, which rate shall be approved by the director of the division of

the budget, to be made by the department to approved organizations for

the cost of health care services coverage pursuant to this title. Such

reimbursement methodologies and fee schedules may include provisions for

capitation arrangements.

(c) The commissioner shall have the authority to promulgate

regulations, including emergency regulations, necessary to effectuate

the provisions of this subdivision.

(d) The department shall require the independent actuary selected

pursuant to paragraph (a) of this subdivision to provide a complete

actuarial report, along with all actuarial assumptions made and all

other data, materials and methodologies used in the development of rates

for the basic health plan authorized under this section. Such report

shall be provided annually to the temporary president of the senate and

the speaker of the assembly.

* 7. Any funds transferred by the secretary of health and human

services to the state pursuant to 42 U.S.C. 18051(d) shall be deposited

in trust. Funds from the trust shall be used for providing health

benefits through an approved organization, which, at a minimum, shall

include essential health benefits as defined in 42 U.S.C. 18022(b); to

reduce the premiums, if any, and cost sharing of participants in the

basic health program; or for such other purposes as may be allowed by

the secretary of health and human services. Health benefits available

through the basic health program shall be provided by one or more

approved organizations pursuant to an agreement with the department of

health and shall meet the requirements of applicable federal and state

laws and regulations.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

* 7. Any funds transferred by the secretary of health and human

services to the state pursuant to 42 U.S.C. 18051(d) shall be deposited

in trust. Funds from the trust shall be used for providing health

benefits through an approved organization, which, at a minimum, shall

include essential health benefits as defined in 42 U.S.C. 18022(b); to

reduce the premiums and cost sharing of participants in the basic health

program; or for such other purposes as may be allowed by the secretary

of health and human services. Health benefits available through the

basic health program shall be provided by one or more approved

organizations pursuant to an agreement with the department of health and

shall meet the requirements of applicable federal and state laws and

regulations.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is

repealed

8. An individual who is lawfully admitted for permanent residence,

permanently residing in the United States under color of law, or who is

a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C.

1101(a)(15), and who would be ineligible for medical assistance under

title eleven of this article due to his or her immigration status if the

provisions of section one hundred twenty-two of this chapter were

applied, shall be considered to be ineligible for medical assistance for

purposes of paragraphs (b) and (c) of subdivision three of this section.

9. Reporting. The commissioner shall submit a report to the temporary

president of the senate and the speaker of the assembly annually by

December thirty-first. The report shall include, at a minimum, an

analysis of the basic health program and its impact on the financial

interest of the state; its impact on the health benefit exchange

including enrollment and premiums; its impact on the number of uninsured

individuals in the state; its impact on the Medicaid global cap; and the

demographics of basic health program enrollees including age and

immigration status.