N.Y.
Public Health Law Section 268-C
Functions of the Marketplace
1.
(a) Perform eligibility determinations for federal and state insurance affordability programs including medical assistance in accordance with Social Services Law § 366 (Eligibility)section three hundred sixty-six of the social services law, child health plus in accordance with § 2511 (Child health insurance plan 1)section twenty-five hundred eleven of this chapter, the basic health program in accordance with Social Services Law § 369-GG (Basic health program)section three hundred sixty-nine-gg of the social services law, the 1332 state innovation program in accordance with Social Services Law § 369-II (1332 state innovation program)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 Social Services Law § 369-GG (Basic health program)section three hundred sixty-nine-gg of the social services law, the 1332 state innovation program in accordance with Social Services Law § 369-II (1332 state innovation program)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 State Finance Law § 98-D (1332 state innovation program fund)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)
Source:
Section 268-C — Functions of the Marketplace, https://www.nysenate.gov/legislation/laws/PBH/268-C (updated May 3, 2024; accessed Dec. 21, 2024).
