There is a newer version of the New York Consolidated Laws
2006 New York Code - Child Health Insurance Plan
§ 2511. Child health insurance plan * 1. (a) The commissioner, in
consultation with the superintendent, shall establish a program to the
extent of funds available therefor through contractual arrangements with
approved organizations to provide covered health care services coverage
for eligible children. The availability of coverage for primary and
preventive health care services and inpatient health care services
coverage shall be continued pending approval of contractual arrangements
that include covered health care services coverage and implementation of
such coverage to the extent of funds available therefor.
(b) Coverage for covered health care services shall not be effective
until such time as contractual arrangements are executed pursuant to
this section for such purposes and an eligible child is enrolled in the
program.
* NB Effective until July 1, 2007
* 1. (a) The commissioner, in consultation with the superintendent,
shall establish a program to the extent of funds available therefor
through contractual arrangements with approved organizations to provide
primary and preventive health care services coverage and inpatient
health care services coverage for eligible children. The availability of
coverage for primary and preventive health care services shall be
continued pending approval of contractual arrangements that include
inpatient health care services coverage and implementation of such
coverage to the extent of funds available therefor.
(b) Coverage for inpatient health care services shall not be effective
until such time as contractual arrangements are executed pursuant to
this section for such purposes and an eligible child is enrolled in the
program.
* NB Effective July 1, 2007
2. In order to be eligible for a subsidy payment pursuant to
subdivision three of this section, a child shall meet the following
criteria:
* (a) (i) effective January first, nineteen hundred ninety-nine,
resides in a household having a net household income at or below one
hundred ninety-two percent of the non-farm federal poverty level (as
defined and updated by the United States department of health and human
services) or the gross equivalent of such net income; and
(ii) effective July first, two thousand, resides in a household having
a net household income at or below two hundred eight percent of the
non-farm federal poverty level (as defined and updated by the United
States department of health and human services) or the gross equivalent
of such net income;
* NB Effective until July 1, 2007
* (a) resides in a household having a net household income at or below
one hundred eighty-five percent of the non-farm federal poverty level
(as defined and annually revised by the federal office of management and
budget) or the gross equivalent of such net income;
* NB Effective July 1, 2007
(b) is not eligible for medical assistance, except that a child who
becomes eligible for medical assistance after becoming an eligible child
under this title, may be eligible for a subsidy payment pursuant to
subdivision three of this section as medical assistance for a period up
to three months after becoming eligible for medical assistance; and
(c) does not have health care coverage under insurance, as defined by
the commissioner, in consultation with the superintendent. The applicant
for insurance shall attest to the source and nature of the child's
health care coverage under this paragraph, if any; and
(d) (i) was not covered by a group health plan based upon a family
member's employment, as defined by the commissioner in consultation with
the superintendent of insurance, during the six month period prior to
the date of the application under this title; except in the case of:
(A) loss of employment due to factors other than voluntary separation;
(B) death of the family member which results in termination of
coverage under a group health plan under which the child is covered;
(C) change to a new employer that does not provide an option for
comprehensive health benefits coverage;
(D) change of residence so that no employer-based comprehensive health
benefits coverage is available;
(E) discontinuation of comprehensive health benefits coverage to all
employees of the applicant's employer;
(F) expiration of the coverage periods established by COBRA or the
provisions of subsection (m) of section three thousand two hundred
twenty-one, subsection (k) of section four thousand three hundred four
and subsection (e) of section four thousand three hundred five of the
insurance law; or
(G) termination of comprehensive health benefits coverage due to
long-term disability.
(ii) The implementation of this paragraph shall take effect only upon
the commissioner's finding that insurance provided under this title is
substituting for coverage under group health plans in excess of a
percentage specified by the secretary of the federal department of
health and human services. The commissioner shall notify the legislature
prior to implementation of this paragraph.
(e) is a resident of New York state. Such residency shall be
demonstrated by adequate proof, as determined by the commissioner, of a
New York state street address. If the child has no street address, such
proof may include, but not be limited to, school records or other
documentation determined by the commissioner.
(f) (i) In order to establish income eligibility under this
subdivision at initial application, a household shall provide such
documentation specified in subparagraph (iii) of this paragraph, as
necessary and sufficient to determine a child's financial eligibility
for a subsidy payment under this title. The commissioner may verify the
accuracy of such income information provided by the household by
matching it against income information contained in databases to which
the commissioner has access, including the state's wage reporting system
pursuant to subdivision five of section one hundred seventy-one-a of the
tax law.
(ii) In order to establish income eligibility under this subdivision
at recertification, a household shall attest to all information
regarding the household's income that is necessary and sufficient to
determine a child's financial eligibility for a subsidy payment under
this title and shall provide the social security numbers for each parent
and legally responsible adult who is a member of the household and whose
income is available to the child, subject to subparagraph (v) of this
paragraph. The commissioner may verify the accuracy of such income
information provided by the household by matching it against income
information contained in databases to which the commissioner has access,
including the state's wage reporting system. In the event that there is
an inconsistency between the income information attested to by the
household and any information obtained by the commissioner from other
sources pursuant to this subparagraph, and such inconsistency is
material to the household's eligibility for a subsidy payment under this
title, the commissioner shall require the approved organization to
obtain income documentation from the household as specified in
subparagraph (iii) of this paragraph.
(iii) Income documentation shall include, but not be limited to, one
or more of the following for each parent and legally responsible adult
who is a member of the household and whose income is available to the
child;
(A) current annual income tax returns;
(B) paycheck stubs;
(C) written documentation of income from all employers; or
(D) other documentation of income (earned or unearned) as determined
by the commissioner, provided, however, such documentation shall set
forth the source of such income.
(iv) In the event a household does not provide income documentation
required by subparagraph (iii) of this paragraph within two months of
the approved organization's request, the approved organization shall
disenroll the child at the end of such two month period. Except as
provided in paragraph (c) of subdivision five-a of this section,
approved organizations shall not be obligated to repay subsidy payments
made by the state on behalf of children enrolled during this two month
period.
(v) In the event a household chooses not to provide the social
security numbers required by subparagraph (ii) of this paragraph, such
household shall provide income documentation specified in subparagraph
(iii) of this paragraph as a condition of the child's enrollment.
Nothing in this paragraph shall be construed as obligating a household
to provide social security numbers of parents or legally responsible
adults as a condition of a child's enrollment or eligibility for a
subsidy payment under this title.
* (g) (i) Notwithstanding any inconsistent provision of law to the
contrary and subject to the availability of federal financial
participation under title XIX of the federal social security act, a
child under the age of nineteen shall be presumed to be eligible for
subsidy payments under this title, once during a twelve month period,
beginning on the first day of the enrollment period following the date
that an approved organization determines, on the basis of preliminary
information, that a child whose family's net household income does not
exceed one hundred ninety-two percent or, effective July first, two
thousand, two hundred eight percent of the non-farm federal poverty
level or the gross equivalent of such net income. The presumptive
eligibility period shall continue until the earlier of the date an
eligibility determination is made pursuant to this title or title eleven
of article five of the social services law, or two months after the date
presumptive eligibility begins; provided however, a presumptive
eligibility period may be extended in the event an eligibility
determination under this title or title eleven of article five of the
social services law is not made within such two month period through no
fault of the applicant for insurance for medical assistance. The
commissioner shall assure that children who are enrolled pursuant to
this paragraph receive the appropriate follow-up for a determination of
eligibility for benefits under this title or title eleven of article
five of the social services law prior to the termination of the
presumptive eligibility period. The commissioner shall assure that
children and their families are informed of all available enrollment
sites in accordance with subdivision nine of this section.
(ii) This paragraph shall have no force and effect and presumptive
eligibility under this paragraph shall not be available on and after the
date presumptive eligibility in the medical assistance program becomes
effective and is available pursuant to subdivision four of section three
hundred sixty-four-i and paragraph (u) of subdivision four of section
three hundred sixty-six of the social services law.
* NB Expires July 1, 2007
* (h) The commissioner may, in consultation with the superintendent,
promulgate rules and regulations necessary to prevent fraud and abuse in
eligibility determinations made by approved organizations pursuant to
this subdivision.
* NB Expires July 1, 2007
(j) Where an application for recertification of coverage under this
title contains insufficient information for a final determination of
eligibility for continued coverage, a child shall be presumed eligible
for a period not to exceed the earlier of two months beyond the
preceding period of eligibility or the date upon which a final
determination of eligibility is made based on the submission of
additional data. In the event such additional information is not
submitted within two months of the approved organization's request, the
approved organization shall disenroll the child following the expiration
of such two month period. Except as provided in paragraph (c) of
subdivision five-a of this section, approved organizations shall not be
obligated to repay subsidy payments received on behalf of children
enrolled during this two month period.
2-a. (a) An approved organization that has reasonable cause to believe
that an applicant for insurance, parent or legally responsible adult has
provided false income information may submit tax returns and any other
available income information, including, if not prohibited by federal
law for purposes of income verification, social security account
numbers, to the department as may be necessary to determine income
eligibility. The department shall promptly furnish to the department of
taxation and finance, pursuant to the agreements authorized by
subdivision five of section one hundred seventy-one-a and subdivision
four of section one hundred seventy-one-b of the tax law, the names,
address and social security account numbers, if available, of the
parents and legally responsible adults who are members of the household,
together with a request that the department of taxation and finance,
pursuant to those agreements, promptly ascertain insofar as is possible,
and from the most recent available data, whether the collective income
reported by those individuals exceeds the income eligibility level for
that household, as determined by the department in compliance with
paragraph (a) of subdivision two of this section. The department, in
consultation with the department of taxation and finance, shall
establish a methodology for comparing numerical equivalents. In
ascertaining whether a household's income exceeds the income eligibility
threshold transmitted by the department, the department of taxation and
finance shall also examine information available pursuant to section one
hundred seventy-one-a of the tax law where any of the named individuals
have failed to file a New York state income tax return for the most
recent filing year or where there is an indication, from the department
or otherwise, that the individual's income may have changed. Reliance on
such section one hundred seventy-one-a information shall be specially
indicated in the department of taxation and finance's response. This
provision shall not be construed to authorize the department of taxation
and finance to disclose any figure on any personal income tax return.
The department shall promptly inform the approved organization of the
response from the department of taxation and finance. Submission of
income information for verification shall not delay the application of
any other provision of this section to an applicant for insurance or an
enrolled child.
(b) Before an approved organization submits income information to the
department for verification with the department of taxation and finance,
it shall:
(i) provide the applicant for insurance with notification of its
intent to seek such verification;
(ii) notify the applicant for insurance of the confidentiality and
expungement provisions contained in paragraph (c) of this subdivision;
and
(iii) provide the applicant for insurance with the opportunity to
review and modify the income information.
(c) Such income information and verification response by the
department of taxation and finance shall not be a public record and
shall not be released by the department, the department of taxation and
finance or the approved organization except pursuant to this
subdivision. Information disclosed pursuant to this section shall be
limited to information necessary for verification. Information so
disclosed shall be kept confidential by the party receiving such
information. Such income information shall be expunged within a
reasonable time to be determined by the department and the department of
taxation and finance.
3. Subsidy payments shall be made, pursuant to subdivision eight of
this section, to approved organizations for the purposes of subsidizing
the entire cost of coverage for eligible children meeting the criteria
of subdivision two of this section. Notwithstanding any inconsistent
provision of this subdivision, the total annual aggregate cost-sharing
with respect to all eligible children in a family under this section
shall not exceed amounts provided pursuant to applicable federal law. In
order to be eligible for a subsidy payment pursuant to this subdivision
a premium payment shall be paid for an eligible child in accordance with
the provisions of subdivision nine of section twenty-five hundred ten of
this title. Nothing herein shall preclude payment of the premium on
behalf of an eligible child on a monthly, quarterly, semi-annual or
annual basis.
* 4. Households shall report to the approved organization, within
thirty days, any changes in New York state residency or health care
coverage under insurance that may make a child ineligible for subsidy
payments pursuant to this section. Any individual who, with the intent
to obtain benefits, willfully misstates income or residence to establish
eligibility pursuant to subdivision two of this section or willfully
fails to notify an approved organization of a change in residence or
health care coverage pursuant to this subdivision shall repay such
subsidy to the commissioner. Individuals seeking to enroll children for
coverage shall be informed that such willful misstatement or failure to
notify shall result in such liability.
* NB Effective until July 1, 2007
* 4. Subsidy payments shall be made, pursuant to subdivision eight of
this section, to approved organizations for the purposes of subsidizing
a portion of the cost of coverage for optional primary and preventive
health services for eligible children meeting the criteria of
subdivision two of this section. The commissioner pursuant to regulation
shall determine the costs to be borne by those individuals enrolled in
optional primary and preventive health care services and shall take into
account the household size and gross annual income.
* NB Effective July 1, 2007
* 4-a. Any individual who, with the intent to obtain benefits,
willfully misstates income or residence to establish eligibility
pursuant to subdivision two of this section or willfully fails to notify
an approved organization of an increase in income or change in residence
pursuant to subdivision two of this section shall repay such subsidy to
the commissioner. Individuals seeking to enroll children for coverage
shall be informed that such willful misstatement or failure to notify
shall result in such liability.
* NB Effective July 1, 2007
* 5. Notwithstanding any inconsistent provisions of subdivision two of
this section, an individual who meets the criteria of paragraphs (b)and
(c) but not the criteria of paragraph (a) of such subdivision may be
enrolled for covered health care services, provided however, that an
approved organization shall not be eligible to receive a subsidy payment
for providing coverage to such individuals. The cost of coverage shall
be determined by the commissioner, in consultation with the
superintendent and shall be no more than the cost of providing such
coverage.
* NB Effective until July 1, 2007
* 5. Notwithstanding any inconsistent provisions of subdivision two of
this section, an individual who meets the criteria of paragraphs (b) and
(c) but not the criteria of paragraph (a) of such subdivision may be
enrolled for primary and preventive health care services, or optional
primary and preventive health care services, and inpatient health care
services, provided however, that an approved organization shall not be
eligible to receive a subsidy payment for providing coverage to such
individuals. The cost of coverage shall be determined by the
commissioner, in consultation with the superintendent and shall be no
more than the cost of providing such coverage.
* NB Effective July 1, 2007
5-a. Obligations of approved organizations. (a) An approved
organization shall have the obligation to review all information
provided pursuant to subdivision two of this section and shall not
certify or recertify a child as eligible for a subsidy payment unless
the child meets the eligibility criteria.
(b) An approved organization shall promptly review all information
relating to a potential change in eligibility based on information
provided pursuant to subdivision four of this section. Within at least
thirty days after receipt of such information, the approved organization
shall make a determination whether the child is still eligible for a
subsidy payment and shall notify the household and the commissioner if
it determines the child is not eligible for a subsidy payment.
(c) Any approved organization which engages in a pattern and practice
of enrolling or recertifying children who are ineligible pursuant to
subdivision two of this section, as determined by the commissioner, in
consultation with the superintendent, shall be required to repay all
subsidy payments received on account of ineligible children. Improper
enrollment based upon a good faith reliance on documentation which
appears accurate on its face shall not constitute a pattern or practice.
Any such approved organization may also be removed as an approved
organization, provided however, that eligible children shall continue to
receive services until such time as the orderly transition to other
approved organizations can be effected.
6. * The commissioner shall, in consultation with the superintendent,
establish guidelines for the submission of proposals by eligible
organizations for the purposes of providing covered health care services
coverage to eligible children including, but not limited to, the
following components:
* NB Effective until July 1, 2007
* The commissioner shall, in consultation with the superintendent,
establish guidelines for the submission of proposals by eligible
organizations for the purposes of providing primary and preventive
health care services coverage and inpatient health care services
coverage to eligible children including, but not limited to, the
following components:
* NB Effective July 1, 2007
(a) standards for individual enrollment including mechanisms for
presumptive eligibility and annual recertification;
(b) standards for provider enrollment;
* (c) standards for scope of covered health care service benefits;
* NB Effective until July 1, 2007
* (c) standards for scope of primary and preventive health care
service benefits and inpatient health care services benefits;
* NB Effective July 1, 2007
(d) standards for health care provider payment methodologies, provided
however, that levels and methods of payment shall be consistent with
those provided under similar insurance plans;
(e) standards for appropriate utilization review, quality assurance
and case management mechanisms; and
(f) such other criteria which may be deemed necessary.
6-a. The commissioner, in consultation with the superintendent, may
establish a program for cards issued to eligible children which can
store or access information electronically, including the identity of
the child and such other medical data and information as the
commissioner, in consultation with the superintendent, may prescribe.
7. (a) A proposal submitted by an eligible organization shall meet the
following criteria:
(i) designate the geographic area to be served by the program, and
estimate the number of eligible participants and actual participants in
such designated area;
* (ii) assure access to and delivery of high quality, appropriate
covered health care services and, when applicable, include a network of
health care providers in sufficient numbers and geographically
accessible to service program participants;
* NB Effective until July 1, 2007
* (ii) assure access to and delivery of high quality, appropriate
primary and preventive health care services and inpatient health care
services and, when applicable, include a network of health care
providers in sufficient numbers and geographically accessible to service
program participants;
* NB Effective July 1, 2007
(iii) describe the procedures for marketing and determining
eligibility for the health care coverage plan in the program location,
including the designation of other entities which may perform such
functions under contract with the organization;
(iv) describe proposed health care provider payment methodologies;
(v) describe in detail the estimated expenses, including personnel
costs and other types of administrative expenses which will be incurred
in the development and implementation of the program;
(vi) describe the quality assurance, utilization review and case
management mechanisms to be implemented;
(vii) demonstrate the applicant's ability to meet the data analysis
and reporting requirements of the program;
* (viii) describe the benefit package to be offered by the program and
the cost of such benefit package;
* NB Effective until July 1, 2007
* (viii) describe the benefit package including, optional primary and
preventive health care services, to be offered by the program and the
cost of such benefit package;
* NB Effective July 1, 2007
(ix) describe the provisions for arranging for or offering conversion
coverage in the event of termination of coverage under this title;
(x) demonstrate financial feasibility of the program;
(xi) describe the premium, copayments and deductibles to be paid by
program participants who are ineligible for subsidy payments; and
(xii) include such other information as the commissioner and the
superintendent may deem appropriate.
(b) The commissioner, in consultation with the superintendent, shall
make a determination whether to approve, disapprove or recommend
modification of the proposal. In order for a proposal to be approved by
the commissioner, the proposal must also be approved by the
superintendent with respect to the provisions of subparagraphs (viii)
through (xii) of paragraph (a) of this subdivision.
(c) The commissioner, in consultation with the superintendent, shall
ensure, to the extent possible, that child health insurance plan
coverage is available in all geographic areas. The commissioner may
approve more than one approved organization to serve all or part of a
geographic area.
7-a. (a) Notwithstanding any inconsistent provisions of subdivisions
one and three of section two thousand five hundred ten of this title,
subdivisions six and seven of this section, subject to paragraph (b) of
this subdivision, and section one hundred sixty-three of the state
finance law, the commissioner may contract with organizations approved
under section three hundred sixty-four-j of the social services law,
without a competitive bid or request for proposal process, to provide
covered health care services coverage for eligible children pursuant to
this title.
(b) In order to be approved pursuant to this subdivision, an
organization shall meet the criteria set forth in subdivision seven of
this section and shall comply with standards established by the
commissioner, in consultation with the superintendent, pursuant to
subdivision six of this section.
(c) Organizations approved pursuant to this subdivision shall comply
with the requirements of this title and contractual provisions
established thereunder, title XXI of the federal social security act and
any implementing federal regulations, and requirements set forth in the
state child health plan established pursuant to title XXI of the federal
social security act.
8. The commissioner shall determine the amount of funds to be
allocated to an approved organization for the purposes described in
subdivision one of this section within such funds which may be available
for the purposes of this article. Subsidy payments made to approved
organizations on and after April first, two thousand five through March
thirty-first, two thousand six, shall be at amounts approved prior to
April first, two thousand five. Applications for increases to subsidy
payments submitted by approved organizations to the superintendent on or
after January first, two thousand five, shall not be considered for
approval until after March thirty-first, two thousand six. Nothing in
this subdivision shall prohibit decreases in subsidy payments in
accordance with relevant contract provisions.
* 9. (a) The commissioner shall develop and implement locally-tailored
public education, outreach and facilitated enrollment strategies
targeted to children who may be eligible for benefits under this title
or title eleven of article five of the social services law, and may
contract with community based organizations including but not limited
to, child advocacy organizations, providers, school-based health centers
and local government. In awarding contracts, the commissioner shall
consider the extent to which such organizations, or coalitions of
organizations, are able to target efforts effectively in geographic
regions of the state where the proportion of children enrolled under
this title and title eleven of article five of the social services law
is lower than other geographic regions of the state. In approving
entities to undertake activities pursuant to this subdivision, within a
defined geographic region, the commissioner shall make a good faith
effort to assure that a coalition is broadly inclusive of organizations
able to target effectively children who may be eligible under this title
and title eleven of article five of the social services law.
(b) Outreach strategies shall include, but are not limited to:
(i) public education;
(ii) dissemination of outreach materials regarding the availability of
benefits available under this title and title eleven of article five of
the social services law, so long as such materials have been approved by
the commissioner prior to distribution;
(iii) recruitment of children who may be eligible under this title or
title eleven of article five of the social services law, including the
distribution of a common application form for services under such
titles;
(iv) outstationing of persons who are authorized to provide assistance
to families in completing the enrollment application process under this
title and title eleven of article five of the social services law,
including the conduct of personal interviews pursuant to section three
hundred sixty-six-a of the social services law and personal interviews
required upon recertification under such section of the social services
law, in locations, such as community settings, which are geographically
accessible to large numbers of children who may be eligible for benefits
under such titles, and at times, including evenings and weekends, when
large numbers of children who may be eligible for benefits under such
titles are likely to be encountered. Persons outstationed in accordance
with this subparagraph shall be authorized to make determinations of
presumptive eligibility in accordance with paragraph (g) of subdivision
two of section two thousand five hundred and eleven of this title; and
(v) notice by local social services districts to medical assistance
applicants of the availability of benefits under paragraph (g) of
subdivision two of section two thousand five hundred and eleven of this
title.
(c) The commissioner shall assure that persons authorized to determine
eligibility under title eleven of article five of the social services
law are placed in selected community settings.
(d) Subject to the availability of funds therefor, training shall be
provided for outstationed persons and employees of approved
organizations to enable them to disseminate information, facilitate the
completion of the application process under this subdivision, and
conduct personal interviews required by section three hundred
sixty-six-a of the social services law and personal interviews required
upon recertification under such section of the social services law.
(e) The commissioner shall assure that outreach activities are
coordinated with all approved organizations, enrollment brokers and
other relevant entities under this title and title eleven of article
five of the social services law. The commissioner shall periodically
monitor activities of these entities to facilitate the completion of
applications for services and other activities under this subdivision.
Such monitoring may include, but not be limited to, unannounced site
visits. As part of the commissioner's assurance of coordinated outreach
activities, contracts with outreach organizations under this subdivision
shall include enrollment procedures for inquiring into existing
relationships with health care providers and procedures for providing
information about how such relationships may be maintained with respect
to health care coverage under this title and under title eleven of
article five of the social services law.
(f) Prior to entering into a contract under this subdivision, the
commissioner shall require that potential outreach organizations
disclose the nature of any contractual, financial, fiduciary or advisory
relationships they have with any approved organizations providing
covered health care services, and with the department. Applications
submitted by organizations which fail to disclose any such relationships
shall be eliminated from consideration for this program.
(g) The commissioner is authorized to submit one or more amendments to
the appropriate cost allocation plan to enable the state to receive
federal financial participation under title XIX and title XXI of the
federal social security act, and is authorized to modify the
administration of this program in order to obtain the maximum amount of
federal financial participation for its components.
(h) Regardless of the availability of funding for contractual
arrangements, upon application the commissioner may permit additional
community-based organizations and qualified health care providers to
perform education, outreach and facilitated enrollment services in
accordance with this subdivision.
(i) The provisions of this subdivision shall be implemented only to
the extent such provisions are not inconsistent with federal law,
regulation and administrative guidance.
* NB Effective until July 1, 2007
* 9. The commissioner shall, within amounts available therefor,
contract with community-based and other marketing organizations for
purposes of public education, outreach, and recruitment of eligible
children, including the distribution of applications and information
regarding enrollment. In awarding such contracts, the commissioner shall
consider the marketing, outreach and recruitment efforts of approved
organizations, and the extent to which such organizations are able to
effectively target efforts in geographic regions where the proportion of
eligible children enrolled under this title are lower than in other
geographic regions of the state. Community-based organizations shall
include, but not be limited to: day care centers, schools,
community-based diagnostic and treatment centers, and hospitals.
* NB Effective July 1, 2007
10. Notwithstanding any other law or agreement to the contrary, and
except in the case of a child or children who also becomes eligible for
medical assistance, benefits under this title shall be considered
secondary to any other plan of insurance or benefit program, except the
physically handicapped children's program and the early intervention
program, under which an eligible child may have coverage.
11. An approved organization shall submit required reports and
information to the commissioner in such form and at times, at least
annually, as may be required by the commissioner and specified in
contracts and official department of health administrative guidance, in
order to evaluate the operations and results of the program and quality
of care being provided by such organizations. Such reports and
information shall include, but not be limited to, enrollee demographics,
program utilization and expense, and patient care outcomes. In the event
an approved organization fails to submit any required report and
information, as specified in contracts and official department of health
administrative guidance, on or before the due date specified by the
commissioner, the commissioner may reduce the approved organization's
subsidy payments by up to a total of two percent each month for a period
beginning on the first day of the calendar month following the original
due date of the required report and information and continuing until the
last day of the calendar month in which the required report and
information are submitted; provided however, an approved organization
shall not be subject to the percentage reduction under the following
conditions: (a) for any new report for which such organization did not
have reasonable notice which shall be at least sixty days notice of its
requirement, data and submission specifications, and due date by
certified mail to the approved organization's chief financial officer;
or (b) for any report, upon a finding by the commissioner that such
report was not submitted on a timely basis for good cause, which may
include, but not be limited to, additional time required to modify or
add to computer data systems.
12. The commissioner shall, in consultation with the superintendent,
establish procedures to coordinate the child health insurance plan with
the medical assistance program, including but not limited to, procedures
to maximize enrollment of eligible children under those programs by
identification and transfer of children who are eligible or who become
eligible to receive medical assistance and procedures to facilitate
changes in enrollment status for children who are ineligible for
subsidies under this section and for children who are no longer eligible
for medical assistance in order to facilitate and ensure continuity of
coverage. The commissioner shall review, on an annual basis, the
eligibility verification and recertification procedures of approved
organizations under this title to insure the appropriate enrollment of
children. Such review shall include, but not be limited to, an audit of
a statistically representative sample of cases from among all approved
organizations. In the event such review and audit reveals cases which do
not meet the eligibility criteria for coverage set forth in this
section, that information shall be forwarded to the approved
organization and the commissioner for appropriate action.
12-a. The commissioner shall establish procedures to audit approved
organizations for compliance with the requirements of this title,
including the requirements of subdivision twelve of this section,
contractual provisions established thereunder and advisory memoranda
issued by the commissioner, title XXI of the federal social security act
and any implementing federal regulations, and requirements set forth in
the state child health plan established pursuant to title XXI of the
federal social security act. Approved organizations shall comply with
such procedures and make available any data necessary to perform such
audits. Audit procedures shall include, but not be limited to, the
following:
(a) standards and procedures for a preliminary audit to be conducted
on no more than an annual basis;
(b) standards and procedures for the submission of a plan of
correction by an approved organization, including time periods allowed
to implement such plan of correction;
(c) standards and procedures for a second audit, including an exit
conference which provides an approved organization the opportunity to
rebut the composition of the audit sample as representative prior to
recovery of subsidy payments and the imposition of penalties;
(d) standards and procedures for recovery of subsidy payments made for
ineligible children, which, notwithstanding any inconsistent provisions
of this title, may include recoveries based on extrapolated findings
from a statistically representative sample of cases which shall be
actuarially based and consistent with accepted auditing standards; and
(e) standards and procedures for the imposition of penalties for
substantial noncompliance, which may include, but not be limited to,
financial penalties in addition to penalties set forth in section twelve
of this chapter and consistent with applicable federal standards, as
specified in contracts, and contract termination.
13. On or before January first, nineteen hundred ninety-two, the
commissioner shall report to the governor and the legislature on the
implementation of the program of primary and preventive health care
services coverage established pursuant to subdivision one of this
section. Such report shall include, but not be limited to: a status
report on implementation of the program including the number of
individuals enrolled profiled by age and geographic location and the
number and location of contractual arrangements entered into; the impact
of such program on access to primary and preventive health care
services; the effect, expenditures and activities of the community-based
outreach program; the number of children for whom an application for
insurance coverage has been made and enrollees who were determined to be
ineligible and the reasons therefor; and, such other matters as the
commissioner deems appropriate. The commissioner shall report annually
thereafter on the status of such program, and on and after January
first, nineteen hundred ninety-seven including inpatient health care
services, including any recommendations for change or other modification
in such program.
14. The commissioner, in consultation with the superintendent, shall
enter into agreements with one or more persons, not-for-profit
corporations, or other organizations, other than a state employee,
official or agency, for the performance of a comprehensive evaluation of
the implementation and effectiveness of the child health insurance
program. Notwithstanding any inconsistent provision of law, the
commissioner may allocate and distribute from funds otherwise available
for distribution for purposes of this title an amount not to exceed five
hundred thousand dollars for the costs of such evaluation. The
evaluation shall include, but not be limited to:
(a) the overall effect of the child health insurance program on access
to, utilization and quality of primary and preventive health care
services, including, but not limited to, patterns of service
utilization, geographic availability of service providers, possible
reductions in uncompensated care as a result of the program, and
enrollee satisfaction with program administration, services and quality;
(b) the impact of the child health insurance program on the health
status of program participants, including the comparative impact on
families that have a child enrolled in the program and other children
that are not eligible and do not have coverage;
(c) the effect of the child health insurance program on emergency room
utilization, including the effectiveness of preventing inappropriate
utilization;
(d) the geographic accessibility of the child health insurance
program, including the availability and accessibility of service
providers, premium levels and premium increases;
(e) the effect of community-based and statewide outreach education
efforts;
(f) the results of a statistically valid sampling of cases verifying
certification and recertification of eligibility for subsidy payments
under this title including but not limited to data on failure by
approved organizations to adequately verify enrollee eligibility;
(g) any recommendations for programmatic changes to improve the child
health insurance program based on program evaluation and enrollee
satisfaction data; and
(h) a cost and patient outcome comparison of indemnity plans and
managed care plans offered under this program.
A preliminary evaluation shall be submitted to the governor and the
legislature by April first, nineteen hundred ninety-five and a further
evaluation shall be submitted by January first, nineteen hundred
ninety-six.
14-a. The commissioner shall enter into an agreement with one or more
persons, not-for-profit corporations, or other organizations, other than
a state employee, official or agency, for comprehensive research
concerning the health care coverage of children in New York state. The
organization conducting the research shall, at least annually, issue a
report of its findings to the governor and the legislature. The research
shall include, but not be limited to:
(a) a survey of the uninsured in the state;
(b) on-going comprehensive studies of the characteristics of uninsured
children and their families, including demographic characteristics, and
reasons such children and families are uninsured;
(c) the collection and dissemination of data and other relevant
information relating to the health care coverage of children and their
families; and
(d) a review of such factors relating to the uninsured in New York
state as the commissioner, in consultation with the superintendent,
shall require.
15. Notwithstanding any inconsistent provision of section one hundred
twelve or one hundred sixty-three of the state finance law or any other
law, at the discretion of the commissioner without a competitive bid or
request for proposal process:
(a) contractual arrangements with approved organizations to provide
primary and preventive health care services coverage for eligible
children, or with organizations for purposes of public education,
outreach and recruitment of eligible children, in effect in nineteen
hundred ninety-three may be extended to provide for primary and
preventive health care services coverage for eligible children or public
education, outreach and recruitment of eligible children in nineteen
hundred ninety-four and nineteen hundred ninety-five and those
contractual arrangements with approved organizations to provide primary
and preventive health care services coverage for eligible children in
effect for nineteen hundred ninety-five may be extended through June
thirtieth, nineteen hundred ninety-six to provide an uninterrupted
continuation of services and additional time for program evaluation and
may be amended as may be necessary, provided, however, that the
commissioner shall periodically review the process of ensuring adequate
participation of approved organizations under this section; and
(b) contractual arrangements with approved organizations to provide
primary and preventive health care services coverage for eligible
children, or with organizations for purposes of public education,
outreach and recruitment of eligible children in effect in the period
January first, nineteen hundred ninety-six through June thirtieth,
nineteen hundred ninety-six may be extended for public education,
outreach and recruitment of eligible children through December
thirty-first, nineteen hundred ninety-six and to provide for primary and
preventive health care services coverage for eligible children through
such periods for which such coverage continues to apply prior to the
addition of coverage for inpatient health care services to provide an
uninterrupted continuation of services and may be amended as may be
necessary.
* 16. The commissioner and the commissioner of social services shall
jointly develop a simplified application form for coverage under this
title, the medical assistance program and the federal women, infants and
children program, and shall also develop appropriate verification and
sampling procedures for the child health insurance plan in order to
facilitate the appropriate enrollment of eligible children into the
child health insurance plan, the medical assistance program, and the
women, infants and children program. Nothing in this subdivision shall
be construed to require that eligibility documentation requirements for
the services under this title shall apply to the medical assistance
program, nor shall this subdivision be construed to preclude eligibility
for any person pending the development of that application. Such
application shall be available for use by local social services
districts and approved organizations under this title by June thirtieth,
nineteen hundred ninety-four.
* NB Expires July 1, 2007
16-a. The commissioner shall develop a simplified recertification form
for use by approved organizations in renewing coverage for eligible
children under this title. The form shall include requests only for such
information that is: (i) reasonably necessary to determine continued
eligibility for coverage under this title; and (ii) subject to change
since the date of the household's initial application.
17. The commissioner, in consultation with the superintendent, is
authorized to establish and operate a child health information service
which shall utilize advanced telecommunications technologies to meet the
health information and support needs of children, parents and medical
professionals, which shall include, but not be limited to, treatment
guidelines for children, treatment protocols, research articles and
standards for the care of children from birth through eighteen years of
age. Such information shall not constitute the practice of medicine, as
defined in article one hundred thirty-one of the education law.
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