(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 of health to underwrite a 1332 state innovation health
insurance plan pursuant to this section.
(c) "Health care services" means:
(i) the services and supplies as defined by the commissioner of health
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 of health 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 of
health, and
(iii) as defined by the commissioner of health and subject to federal
approval, certain services and supports provided to enrollees 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.
(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 NY State of Health, the official health
Marketplace, or Marketplace, as defined in subdivision two of section
two hundred sixty-eight-a of the public health law.
(e) "Basic health insurance plan" means a 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
section three hundred sixty-nine-gg of this title.
(f) "1332 state innovation plan" means a standard health plan
providing health care services, separate and apart from a qualified
health plan and a basic health insurance plan, that is issued by an
approved organization and certified in accordance with this section.
3. State innovation plan eligible individual. (a) A person is eligible
to receive coverage for health care under this section if they:
(i) reside in New York state and are under sixty-five years of age;
(ii) are 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;
(iii) are 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(f) of such code; and
(iv) have 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 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 section if such noncitizen would be ineligible for
medical assistance under title eleven of this article due to their
immigration status.
(b) Subject to federal approval, a child born to an individual
eligible for and receiving coverage for health care services pursuant to
this section who but for their eligibility under this section would be
eligible for coverage pursuant to subparagraphs two or four of paragraph
(b) of subdivision one of section three hundred sixty-six of this
article, shall be administratively enrolled, as defined by the
commissioner of health, in 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.
(c) Subject to federal approval, an individual who is eligible for and
receiving coverage for health care services pursuant to this section is
eligible to continue to receive health care services pursuant to this
section during the individual's 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 section.
(d) For the purposes of this section, 1332 state innovation program
eligible individuals are prohibited from being treated as qualified
individuals under section 1312 of the Affordable Care Act and as
eligible individuals under section 1331 of the ACA and enrolling in
qualified health plan through the Marketplace or standard health plan
through the Basic Health Program.
4. Enrollment. (a) Subject to federal approval, the commissioner of
health is authorized to establish an application and enrollment
procedure for prospective enrollees. Such procedure will include a
verification system for applicants, which must be consistent with 42 USC
§ 1320b-7.
(b) Such procedure shall allow for continuous enrollment for enrollees
to the 1332 state innovation program where an individual may apply and
enroll for coverage at any point.
(c) Upon an applicant's enrollment in a 1332 state innovation plan,
coverage for health care services pursuant to the provisions of this
section shall be retroactive to the first day of the month in which the
individual was determined eligible, except in the case of program
transitions within the Marketplace.
(d) A person who has enrolled for coverage pursuant to this section,
and who loses eligibility to enroll in the 1332 state innovation 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 section, 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 their
eligibility for coverage continued until the end of such twelve month
period, provided that the state receives federal approval for using
funds under an approved 1332 waiver.
5. Premiums. Subject to federal approval, the commissioner of health
shall establish premium payments enrollees in a 1332 state innovation
plan shall pay to approved organizations for coverage of health care
services pursuant to this section. Such premium payments shall be
established in the following manner:
(a) up to fifteen dollars monthly for an individual with a household
income above two hundred percent of the federal poverty line but 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
(b) 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.
6. Cost-sharing. The commissioner of health shall establish
cost-sharing obligations for enrollees, subject to federal approval,
including childbirth and newborn care consistent with the medical
assistance program under title eleven of this article. There shall be no
cost-sharing obligations for enrollees for:
(a) dental and vision services as defined in subparagraph (ii) of
paragraph (c) of subdivision two of this section; and
(b) services and supports as defined in subparagraph (iii) of
paragraph (c) of subdivision two of this section.
7. Rates of payment. (a) The commissioner of health 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 section. 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 of health shall
develop reimbursement methodologies and fee schedules for determining
rates of payment, which rates 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 section. Such reimbursement methodologies and fee schedules may
include provisions for capitation arrangements.
(c) The commissioner of health shall have the authority to promulgate
regulations, including emergency regulations, necessary to effectuate
the provisions of this subdivision.
(d) The department of health 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 1332 state innovation plan authorized under this section.
Such report shall be provided annually to the temporary president of the
senate and the speaker of the assembly.
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 their 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 of health 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 1332 state innovation program and its impact
on the financial interest of the state; its impact on the Marketplace
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 the 1332 state innovation program enrollees including
age and immigration status.
10. Severability. If the secretary of health and human services or the
secretary of the treasury do not approve any provision of the
application for a state innovation waiver, such decision shall in no way
affect or impair any other provisions that the secretaries may approve
under this section.
* NB Effective upon the commissioner of health obtaining and
maintaining all necessary approvals from the secretary of health and
human services and the secretary of the treasury (see chapter 57 of 2023
Part H § 7)