2006 New York Code - Family Health Plus Program

 
    §  369-ee.  Family  health  plus  program. 1. Definitions. (a) "Family
  health insurance plan" means the  written  undertaking  of  an  approved
  organization  to  provide  coverage  of health care services to eligible
  individuals under this title.
    (b) "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 such article.
    (c)  "Approved  organization" means an eligible organization which has
  been  approved  by  the  commissioner  to  underwrite  a  family  health
  insurance plan.
    (d)  "Period of eligibility" means that period commencing on the first
  day of the month following the date when the  individual  (i)  has  been
  determined  eligible  for health care coverage under this title and (ii)
  has enrolled in a family health insurance plan, and ending on  the  last
  day of the month in which an individual ceases to be eligible.
    (e)  "Health  care services" means the following services and supplies
  as defined by the commissioner in consultation with  the  superintendent
  of insurance:
    (i) the services of physicians, nurse practitioners, and other related
  personnel which are provided on an outpatient or inpatient basis;
    (ii)  inpatient  hospital  services  provided by a general hospital, a
  facility operated by the office of mental health under section  7.17  of
  the  mental  hygiene  law,  a  facility  issued an operating certificate
  pursuant to the provisions of article twenty-three or thirty-one of  the
  mental hygiene law;
    (iii) laboratory tests;
    (iv) diagnostic x-rays;
    (v) prescription drugs and non-prescription smoking cessation products
  or devices;
    (vi) durable medical equipment;
    (vii) radiation therapy, chemotherapy, and hemodialysis;
    (viii) emergency room services;
    (ix)  inpatient and outpatient mental health and alcohol and substance
  abuse services, as defined by the commissioner;
    (x) prehospital emergency medical services for  the  treatment  of  an
  emergency  medical  condition  when  such  services  are  provided by an
  ambulance service;
    (xi) emergency, preventive and routine  dental  care,  to  the  extent
  offered  by  a  family  health insurance plan described in this section,
  except orthodontia and cosmetic surgery;
    (xii) emergency vision care, and preventive and routine vision care as
  follows: once in any twenty-four month period:
    (A) one eye examination;
    (B) either: one pair of prescription eyeglass lenses and a  frame,  or
  prescription contact lenses where medically necessary; and
    (C) one pair of medically necessary occupational eyeglasses;
    (xiii) speech and hearing services;
    (xiv) diabetic supplies and equipment;
    (xv) services provided to meet the requirements of 42 U.S.C. 1396d(r);
  and
    (xvi) hospice services.
    (e-1)  "Health care services" shall not include: (i) drugs, procedures
  and supplies for the treatment of erectile dysfunction when provided to,
  or prescribed for use by, a person who is required to register as a  sex
  offender  pursuant  to article six-C of the correction law provided that
  any denial of coverage pursuant to  this  paragraph  shall  provide  the
  patient  with  the  means of obtaining additional information concerning
  both the denial and the means of challenging such denial; (ii) drugs for
  the  treatment  of sexual or erectile dysfunction, unless such drugs are
  used to treat a condition, other than sexual  or  erectile  dysfunction,
  for  which  the  drugs  have  been approved by the federal food and drug
  administration.
    (f) "Managed care provider"  shall  have  the  meaning  set  forth  in
  section three hundred sixty-four-j of this article.
    (g) "Minor child" means, for purposes of this title, a child under the
  age of twenty-one.
    (h)   "Commissioner"  for  purposes  of  this  title  shall  mean  the
  commissioner of health.
    (i) "Resources" for purposes of this title shall have the same meaning
  as determined in accordance with paragraph (a)  of  subdivision  two  of
  section  three  hundred  sixty-six  of  this  title except that the term
  savings referred to in subparagraph four of such paragraph shall mean an
  amount equal to at least one hundred fifty  percent  of  the  applicable
  allowable  income  amount  permitted  under  subparagraph  seven of such
  paragraph.
    2. Eligibility. (a) A  person  is  eligible  to  receive  health  care
  services pursuant to this title if he or she:
    (i)  resides in New York state and is at least age nineteen, but under
  sixty-five years of age;
    (ii) is not eligible for medical assistance under title eleven of this
  article solely due to income or resources or  is  eligible  for  medical
  assistance   under  title  eleven  of  this  article  only  through  the
  application of excess income  toward  the  costs  of  medical  care  and
  services  pursuant to subdivision two of section three hundred sixty-six
  of title eleven of this article;
    * (iii) does not have equivalent health care coverage under  insurance
  or equivalent mechanisms, as defined by the commissioner in consultation
  with the superintendent of insurance;
    * NB Effective until amendment approved by the commissioner of health
    * (iii)  does not have equivalent health care coverage under insurance
  or equivalent mechanisms, as defined by the commissioner in consultation
  with the superintendent of insurance,  and  is  not  a  federal,  state,
  county,  municipal  or  school  district  employee  that is eligible for
  health care coverage through his or her employer;
    * NB Effective upon approval by the commissioner of health
    * (iv) (A) was not covered by a group health plan based  upon  his  or
  her  employment  or  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:
    (I) loss of employment due to factors other than voluntary separation;
    (II) death of a family member which  results  in  termination  of  the
  applicant's coverage under the group health plan;
    (III)  change  to  a  new employer that does not provide an option for
  comprehensive health benefits coverage;
    (IV) change of  residence  so  that  no  employer-based  comprehensive
  health benefits coverage is available;
    (V)  discontinuation  of comprehensive health benefits coverage to all
  employees of the applicant's employer;
    (VI) 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;
    (VII)  termination  of  comprehensive  health benefits coverage due to
  long-term disability;
    (VIII) loss of employment due to need to care for a child or  disabled
  household member or relative; or
    (IX)  reduction  in  wages  or  hours  or  an  increase in the cost of
  coverage so that coverage is no longer affordable or available.
    (B) the implementation of this subparagraph  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 pursuant to subparagraph (ii) of paragraph  (d)  of
  subdivision  two  of  section  twenty-five  hundred eleven of the public
  health law.
    * NB Effective until amendment approved by the commissioner of health
    * (iv) (A) was not covered by a group health plan based  upon  his  or
  her  employment  or  a  family  member's  employment,  as defined by the
  commissioner in  consultation  with  the  superintendent  of  insurance,
  during  the nine-month period prior to the date of the application under
  this title, except in the case of:
    (I) loss of employment due to factors other than voluntary separation;
    (II) death of a family member which  results  in  termination  of  the
  applicant's coverage under the group health plan;
    (III)  change  to  a  new employer that does not provide an option for
  comprehensive health benefits coverage;
    (IV) change of  residence  so  that  no  employer-based  comprehensive
  health benefits coverage is available;
    (V)  discontinuation  of comprehensive health benefits coverage to all
  employees of the applicant's employer;
    (VI) 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;
    (VII) termination of comprehensive health  benefits  coverage  due  to
  long-term disability;
    (VIII)  loss of employment due to need to care for a child or disabled
  household member or relative; or
    (IX) reduction in wages or  hours  or  an  increase  in  the  cost  of
  coverage so that coverage is no longer affordable or available.
    (B)  the  implementation  of  this subparagraph 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  pursuant to subparagraph (ii) of paragraph (d) of
  subdivision two of section twenty-five  hundred  eleven  of  the  public
  health law.
    * NB Effective upon approval by the commissioner of health
    (v) (A) in the case of a parent or stepparent of a child under the age
  of  twenty-one  who lives with such child, has gross family income equal
  to or less than the applicable percent of the  federal  income  official
  poverty  line (as defined and updated by the United States Department of
  Health and Human Services) for a family of the same size;  for  purposes
  of this clause, the applicable percent effective as of:
    (I)  January  first,  two thousand one, is one hundred twenty percent;
  and
    (II) October first, two thousand  one,  is  one  hundred  thirty-three
  percent; and
    (III)  October  first, two thousand two, is one hundred fifty percent;
  or
    (B)  in  the  case  of an individual who is not a parent or stepparent
  living with his or her child under the  age  of  twenty-one,  has  gross
  family  income  equal to or less than one hundred percent of the federal
  income official poverty line (as  defined  and  updated  by  the  United
  States Department of Health and Human Services) for a family of the same
  size.
    (b)  In  order to establish income eligibility under this subdivision,
  an individual shall provide  such  documentation  as  is  necessary  and
  sufficient   to   initially,   and  annually  thereafter,  determine  an
  applicant's  eligibility   for   coverage   under   this   title.   Such
  documentation  shall  include,  but  not be limited to the following, if
  needed to verify eligibility:
    (i) paycheck stubs; or
    (ii) written documentation of income from all employers; or
    (iii) other documentation of income (earned or unearned) as determined
  by the commissioner, provided  however,  such  documentation  shall  set
  forth the source of such income; and
    (iv)   proof   of   identity   and  residence  as  determined  by  the
  commissioner.
    (c) For the purposes of this title,  the  determination  of  resources
  shall be in accordance with paragraphs (b) and (c) of subdivision two of
  section three hundred sixty-six-a of this article.
    2-a.  Co-payments. Subject to federal approval pursuant to subdivision
  six of this section, persons receiving family health plus coverage under
  this section shall be responsible to make co-payments in accordance with
  the terms of subdivision six of section three hundred  sixty-seven-a  of
  this  article,  including  those  individuals who are otherwise exempted
  under  the  provisions  of  subparagraph  (iv)  of  paragraph   (b)   of
  subdivision  six of section three hundred sixty-seven-a of this article,
  provided however, that notwithstanding the provisions of paragraphs  (c)
  and (d) of such subdivision:
    (i)  co-payments  charged for each generic prescription drug dispensed
  shall be three  dollars  and  for  each  brand  name  prescription  drug
  dispensed shall be six dollars;
    (ii)  the  co-payment  charged  for each dental service visit shall be
  five dollars, provided that no enrollee shall be required  to  pay  more
  than  twenty-five  dollars  per year in co-payments for dental services;
  and
    (iii) the co-payment for clinic services and physician services  shall
  be five dollars;
  and  provided  further  that  the  limitations  in paragraph (f) of such
  subdivision shall not apply.
    3. (a) Every person determined eligible for or receiving family health
  plus coverage under  this  section  shall  enroll  in  a  family  health
  insurance plan.
    (b)  Participants  shall  select  a  family health insurance plan from
  among those designated under the family health plus program.
    (c) Participants under this section who have  lost  their  eligibility
  for  health care services before the end of a six month period beginning
  on the date of the participant's initial enrollment in a  family  health
  insurance  plan  shall  have  their  eligibility  for family health plus
  continued until the end of the six  month  enrollment  period,  provided
  that  federal  financial  participation  in the cost of such coverage is
  available.
    (d) Family health insurance plans shall assure access to and  delivery
  of  high quality, cost effective, appropriate health care services. Such
  plans shall include a network of health  care  providers  in  sufficient
  numbers  which  are  geographically  accessible  to program participants
  consistent with the following provisions:
    (i)  approved  organizations  shall adhere to marketing and enrollment
  guidelines established by the commissioner, which shall include but  not
  be  limited  to  marketing  and  enrollment  encounters between approved
  organizations and prospective enrollees, locations for such  encounters,
  and   prohibitions   against  telephone  cold-calling  and  door-to-door
  solicitation  at  the   homes   of   prospective   enrollees.   Approved
  organizations  shall  be  permitted  to  assist prospective enrollees in
  completion of enrollment forms at approved health  care  provider  sites
  and other approved locations. In no case may an emergency room be deemed
  an  approved  location.  Approved  organizations shall submit enrollment
  forms to the local department of social services.
    (ii) any marketing materials developed  by  an  approved  organization
  shall be approved by the department of health within sixty days prior to
  distribution to prospective enrollees of family health insurance.
    (iii)  a  family  health  insurance plan requesting disenrollment of a
  participant shall not disenroll a participant without the prior approval
  of the local district in which the participant resides. A family  health
  insurance plan shall not request disenrollment of a participant based on
  any  diagnosis,  condition,  or  perceived  diagnosis or condition, or a
  participant's efforts to exercise his or her rights  under  a  grievance
  process.
    (iv)  a  family  health  insurance  plan shall implement procedures to
  communicate  appropriately  with  participants   who   have   difficulty
  communicating   in   English   and  to  communicate  appropriately  with
  visually-impaired and hearing-impaired participants.
    (v) a family health insurance plan shall comply with applicable  state
  and  federal  law  provisions prohibiting discrimination on the basis of
  disability.
    (vi) a family health insurance  plan  shall  establish  procedures  to
  comply  with  subparagraph (iii) of paragraph (a) of subdivision four of
  section three hundred sixty-four-j of this article.
    (e) The family health plus  program  shall  be  operated  by  approved
  organizations  which  are  authorized  to  arrange for care and services
  pursuant  to  this  section  provided  however  that,  unless  otherwise
  specified in this title, paragraphs (c), (s), (t) and (u) of subdivision
  one,  paragraph  (b)  of  subdivision two, subdivision three, paragraphs
  (b), (c), (d), subparagraphs (i), (iv), (v), (vi), (vii), and (viii)  of
  paragraph  (e),  paragraphs  (f),  (g), (i) and (l) of subdivision four,
  subdivisions  five,  seven,  eleven  and  twelve,   paragraph   (a)   of
  subdivision  thirteen,  subdivisions  fourteen,  fifteen  and seventeen,
  paragraph (b)  of  subdivision  eighteen  and  subdivisions  twenty  and
  twenty-one  of  section three hundred sixty-four-j of this article shall
  not apply and provided further that provisions addressing  provision  of
  benefits by special needs plans shall not apply.
    (f)  Notwithstanding  any  inconsistent  provisions  of this title and
  section one hundred sixty-three  of  the  state  finance  law:  (i)  the
  commissioner  may  contract  with  managed care providers approved under
  section three hundred sixty-four-j of this article  or  title  one-A  of
  article  twenty-five  of the public health law without a competitive bid
  or request for proposal  process  to  provide  family  health  insurance
  coverage  for eligible individuals pursuant to this title; (ii) in areas
  of the state which do not have sufficient managed care  access  to  meet
  the  objectives  of  this  section,  the  commissioner may contract with
  entities approved pursuant to title one-A of article twenty-five of  the
  public health law.
    (g)  The  care  and  services  described under subdivision one of this
  section will be furnished by a family health insurance plan pursuant  to
  the  provisions  of  this  section  when  such services are furnished in
  accordance with an agreement with the  department  of  health  and  meet
  applicable federal laws and regulations.
    (h)  The commissioner may delegate some or all of the tasks identified
  in this section to local districts provided that the  agreement  between
  the  department  of  health  and  such plan pursuant to this subdivision
  clearly reflects such delegation.
    4. (a) The commissioner shall develop and  implement  locally-tailored
  education,  outreach  and  facilitated enrollment strategies targeted to
  individuals who may be eligible for benefits under this title  or  title
  eleven  of  this  article.  Such  strategies  shall  include, but not be
  limited to, contracting with community-based  organizations  to  perform
  education,   outreach   and  facilitated  enrollment.  In  awarding  the
  contracts, the commissioner shall  consider  the  extent  to  which  the
  organizations,  or  coalitions  of  organizations,  are  able  to target
  efforts effectively in  geographic  areas  in  which  there  is  a  high
  proportion  of  uninsured  individuals  and a low proportion of eligible
  individuals receiving benefits under title eleven of  this  article.  In
  approving   organizations  to  undertake  activities  pursuant  to  this
  subdivision, within a defined geographic region, the commissioner  shall
  make  a  good  faith effort to ensure that the organizations are broadly
  inclusive of organizations in the  region  able  to  target  effectively
  individuals  who  may be eligible for coverage under this title or title
  eleven of this article.
    (b) Outreach strategies shall include but shall not be limited to:
    (i) public education;
    (ii) dissemination of materials regarding the availability of benefits
  available under this title, title eleven  of  this  article,  and  title
  one-A  of  article  twenty-five  of the public health law, provided that
  such  materials  have  been  approved  by  the  commissioner  prior   to
  distribution;
    (iii)  development  of  an  application  form  for services under this
  program and for services under title eleven of this article that is easy
  to understand and complete;
    (iv) outstationing of persons who are authorized to provide assistance
  to individuals in completing the application process under  this  title,
  title  eleven of this article, and title one-A of article twenty-five of
  the public health law  including  the  conduct  of  personal  interviews
  pursuant  to  section  three  hundred  sixty-six-a  of this chapter upon
  initial application. Such locations shall include but not be limited  to
  offices  of approved organizations, which shall be authorized to conduct
  personal interviews. Outstationing shall take place in  locations  which
  are geographically accessible to large numbers of individuals who may be
  eligible  for  benefits  under  such  titles,  and  at  times, including
  evenings and weekends, when large numbers  of  individuals  who  may  be
  eligible for benefits under such titles are likely to be encountered. In
  the  event  that  a  photograph  of  the  participant is required for an
  identification  card,  other  than  a   photograph   supplied   by   the
  participant, the commissioner shall exercise best efforts to assure that
  such  photograph  can  be  taken in geographically accessible locations,
  including the offices of approved organizations.
    (c) The commissioner shall:
    (i) ensure that training is furnished  for  outstationed  persons  and
  employees  of  approved  organizations  to  enable  them  to disseminate
  information and facilitate the completion  of  the  application  process
  under  this  title,  title  eleven  of  this article, and title one-A of
  article twenty-five of the public health law;
    (ii)  ensure  that outreach strategies and activities under this title
  are coordinated with such strategies and activities under title one-A of
  article twenty-five of the public health  law,  and  with  all  approved
  organizations,  enrollment  brokers,  and  other relevant entities under
  this title, title eleven of this article  and  title  one-A  of  article
  twenty-five of the public health law;
    (iii)  periodically  monitor  the  performance of entities involved in
  outreach activities, to assure  that  potentially  eligible  individuals
  receive  accurate  information  in  a  understandable  manner, that such
  individuals are told of the availability of benefits under  this  title,
  title  eleven  of this article and title one-A of article twenty-five of
  the public health  law,  that  such  individuals  are  informed  of  the
  approved  organizations  under this title, title eleven of this article,
  and title one-A of article twenty-five of the  public  health  law,  and
  that  appropriate follow-up is conducted. Such monitoring shall include,
  but shall 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 title eleven of this article.
    (d)   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.
    5.   (a)  Personal  interviews,  pursuant  to  section  three  hundred
  sixty-six-a of this chapter, may be required  upon  initial  application
  only  and  may  be  conducted  in community settings. Recertification of
  eligibility shall take place on no more than an annual basis  and  shall
  not  require  a  personal  interview.  Nothing  herein shall abridge the
  participant's obligation  to  report  changes  in  residency,  financial
  circumstances or household composition.
    (b)  Sections  twenty-three and twenty-three-a of chapter four hundred
  thirty-six of the laws of nineteen hundred ninety-seven shall not  apply
  to  applicants  for  or  recipients  of  health care services under this
  title.
    (c) Except where inconsistent with the provisions of this  title,  the
  provisions of title eleven of this article shall apply to applicants for
  and recipients under this title.
    * 6. Waivers and federal approvals. (a) The provisions of this section
  shall  not  take effect unless all necessary approvals under federal law
  and  regulation  have  been  obtained  to  receive   federal   financial
  participation,  under  the  program  described  in  title eleven of this
  article, in the costs of health care services provided pursuant to  this
  section.
    (b)  The  commissioner is authorized to submit amendments to the state
  plan for medical assistance and/or submit one or more  applications  for
  waivers  of  the  federal  social  security  act,  to obtain the federal
  approvals necessary to implement this section.  The  commissioner  shall
  submit   such   amendments  and/or  applications  for  waivers  by  June
  thirtieth, two thousand, and  shall  use  best  efforts  to  obtain  the
  approvals required by this subdivision in a timely manner so as to allow
  early implementation of this section.
    * NB U.S. Sec. of Health and Human Services granted approval per &#1671115
  of Social Security Act on June 1, 2001
    7.  The  commissioner  shall  promulgate  any regulations necessary to
  implement this title.