2012 New York Consolidated Laws
SOS - Social Services
Article 5 - ASSISTANCE AND CARE
Title 11-D - (369-EE - 369-FF) FAMILY HEALTH PLUS PROGRAM
369-FF - Employer partnerships for family health plus.

 
    §  369-ff.  Employer  partnerships  for  family health plus. 1. (a) An
  employer or other designated sponsor may elect to  offer  family  health
  plus  insurance  plans  approved under the family health plus program to
  all employees or members and family members of employees or members.  If
  an  employer  or other designated sponsor chooses to offer family health
  plus insurance plans, the employer or other designated sponsor shall pay
  to the commissioner or the commissioner's designee a sum of money  equal
  to  at least seventy percent of the premium or a fixed dollar amount, as
  determined by the commissioner, applicable to each enrolling employee or
  member. Each employee or member who enrolls shall, through the  employer
  or   other   designated   sponsor,   pay  to  the  commissioner  or  the
  commissioner's designee the balance of the premium. If the employee's or
  member's share of the premium  is  covered  by  the  employer  sponsored
  health  coverage or premium assistance programs set forth in this title,
  title eleven of this article, or title one-A of article  twenty-five  of
  the  public  health  law,  then  the employee's or member's share of the
  premium shall be paid under such program. Notwithstanding any  provision
  of  law,  rule  or regulation to the contrary, the commissioner may, for
  children under  the  age  of  twenty-one,  require  family  health  plus
  insurance  plans  to  cover  all  benefits  covered under title one-A of
  article twenty-five of the public health law.
    (b) Where an employer or other designated  sponsor  chooses  to  offer
  family  health plus insurance plans under this section, such employer or
  other designated sponsor shall disseminate to all employees  or  members
  information  regarding  employer  sponsored  health  coverage or premium
  assistance programs set forth  in  this  title,  title  eleven  of  this
  article, or title one-A of article twenty-five of the public health law.
  The  information  shall  be provided by the commissioner to employers or
  other designated sponsors offering family  health  insurance  plans  and
  disseminated  by  employers or other designated sponsors to employees or
  members in a form and manner specified by the commissioner.
    (c) Subject to federal  approval,  an  employer  or  other  designated
  sponsor  choosing  to  offer  family  health  plus  insurance  plans  in
  accordance with paragraph (a) of this  subdivision  which  (i)  did  not
  previously  offer  health  insurance to its employees or members or (ii)
  currently offers health insurance to its employees or  members  but  the
  employer's  or  other  designated sponsor's ability to continue to offer
  such coverage is in jeopardy, as determined by the commissioner, may  be
  eligible  for  state  subsidies  towards  the  cost  of its share of the
  premium only for employees or members who otherwise may be eligible  for
  family  health  plus, child health plus or medical assistance under this
  title, title one-A of article twenty-five of the public  health  law  or
  title  eleven  of  this  article,  respectively.  An  employee or member
  identified as potentially eligible for family health plus, child  health
  plus   or   medical  assistance  through  a  process  specified  by  the
  commissioner shall apply to the appropriate program for  an  eligibility
  determination.  The  availability and amount of state subsidies provided
  pursuant to this paragraph and eligibility criteria for  such  subsidies
  shall  be  determined  by  the commissioner. State subsidies pursuant to
  this paragraph shall be cost effective relative to payments  made  under
  the  family  health  plus,  child  health  plus  and  medical assistance
  programs, whichever program is applicable.
    (d) All moneys paid to the commissioner under this  section  shall  be
  deposited  by  the  commissioner  in  the  family  health  plus employer
  partnership account established under section ninety-one-g of the  state
  finance law. Notwithstanding any provision of law, rule or regulation to
  the  contrary,  the  commissioner  may issue a request for proposals and

  enter  into  one  or  more  contracts  to  administer  the  billing  and
  collection of premiums due under this section.
    (e)  The  commissioner or the commissioner's designee is authorized to
  act as a health plan coordinator between employers or  other  designated
  sponsors  and  health plans if the commissioner determines that a health
  plan coordinator will be helpful in the effective implementation of this
  section or in facilitating the offering  of  multiple  health  plans  by
  employers  or  other  designated sponsors to their employees or members.
  The commissioner  is  also  authorized  to  amend  existing  facilitated
  enrollment contracts if necessary to implement this section.
    (f)  For purposes of this section, the term "other designated sponsor"
  means: a Taft-Hartley fund or a voluntary employee  benefit  association
  established  in accordance with the requirements of section 501(c)(9) of
  the federal internal revenue code.
    2. Individuals enrolled in family health plus plans under this section
  shall not count towards  the  percentage  specified  in  clause  (B)  of
  subparagraph  (iv)  of paragraph (a) of subdivision two of section three
  hundred sixty-nine-ee of this title or towards the percentage  specified
  in  subparagraph  (ii)  of  paragraph  (d) of subdivision two of section
  twenty-five hundred eleven of the public health law.
    3. Coverage under this  section  shall  be  community  rated  and  the
  underwriting  of such coverage shall involve no more than the imposition
  of a pre-existing condition limitation as  permitted  by  the  insurance
  law.  Any  employee  or member or family member of an employee or member
  applying for coverage under such paragraph must be accepted by the  plan
  at  all times throughout the year and cannot be terminated due to claims
  experience. Termination of coverage may be based only on one or more  of
  the  reasons  set forth in subsection (c) of section four thousand three
  hundred four or subsection (j) of section four  thousand  three  hundred
  five  of  the  insurance  law.  For  the  purposes  of this subdivision,
  "community rated" means a rating methodology in which  the  premium  for
  all  persons  covered by a policy or contract form is the same, based on
  the experience of the entire pool of risks covered  by  that  policy  or
  contract  form  without  regard to age, sex, health status or occupation
  except that the pool of risks shall exclude individuals  enrolled  in  a
  family   health   plus   insurance  plan  under  section  three  hundred
  sixty-nine-ee of this title if required by federal regulations governing
  actuarial soundness  for  Medicaid  managed  care  premium  rates.  This
  subdivision  does  not  prohibit  the  use of premium rate structures to
  establish different premium rates for individuals as opposed  to  family
  units. The premium or premiums for coverage under paragraphs (a) and (c)
  of  subdivision  one  of  this  section  shall  be  established  by  the
  commissioner.
    4. The state share of  the  cost  of  coverage  provided  pursuant  to
  paragraph  (c) of subdivision one of this section shall be funded within
  amounts appropriated for this purpose.
    5. (a) Individuals enrolled in  family  health  plus  insurance  plans
  under this section who are not otherwise eligible for family health plus
  under  section  three  hundred  sixty-nine-ee  of  this  title  shall be
  responsible  to  make  co-payments  in  accordance  with  the  terms  of
  paragraph  (b)  of  this  subdivision;  provided  however that the total
  amount of any co-payments which an individual shall be required to  make
  may not exceed two thousand dollars per annum.
    (b) Co-payments may be charged in the following amounts:
    (i)  the  co-payment charged for each discharge for inpatient care may
  be up to one hundred fifty dollars;
    (ii) The co-payment charged for each emergency room visit may be up to
  fifty dollars;

    (iii) the co-payment charged for each outpatient surgery may be up  to
  one hundred dollars;
    (iv)  the  co-payment  charged  for each primary care physician office
  visit, for each dental service visit, for each laboratory  service,  for
  each  radiology  service, for each outpatient mental health service, and
  for each outpatient substance abuse service may be up to ten dollars;
    (v) the co-payment  charged  for  each  physician  specialist  service
  office  visit,  for each physical therapy service, for each occupational
  therapy service, for each  speech  therapy  service,  for  each  hearing
  service,  for each vision service, and for each podiatric service may be
  up to twenty-five dollars; and
    (vi)  the  co-payment  charged  for  each  generic  prescription  drug
  dispensed may be up to five dollars and for each brand name prescription
  drug dispensed may be fifteen dollars.
    (c)  An  individual who is eligible for coverage under a family health
  plus insurance plan pursuant to section three hundred  sixty-nine-ee  of
  this  title shall make co-payments in accordance with such section three
  hundred sixty-nine-ee and shall not  make  co-payments  as  provided  in
  paragraph (b) of this subdivision.
    (d)  An  employer  or  designated  sponsor participating in the family
  health plus program on or before July first, two  thousand  ten,  or  an
  employer  or  other  designated sponsor who entered into a memorandum of
  understanding with the state on or before July first, two  thousand  ten
  with  respect  to  the  purchase of health insurance coverage under this
  section for child care providers represented by such sponsor, shall have
  the option to establish co-payments in  accordance  with  section  three
  hundred  sixty-nine-ee  of  this  title  or  to establish co-payments as
  provided in paragraph (b) of this subdivision.
    6. Notwithstanding any law, rule or regulation to  the  contrary,  the
  commissioner  may  amend  the application requirements for employees who
  may be eligible for family health plus  insurance  plans  to  limit  and
  simplify  application documentation requirements, provided however, such
  application requirements shall otherwise comply with federal law.
    7. Where a health care service under a family  health  plus  insurance
  plan   is  not  covered  under  a  payment  rate  methodology  agreement
  negotiated with a general hospital, the rate of  payment  for  emergency
  and inpatient hospital services shall be in accordance with subparagraph
  (i)  of  paragraph  (a-2)  of  subdivision  one  of section twenty-eight
  hundred seven-c of the public health law.
    8. An employer or other designated sponsor shall not  be  eligible  to
  offer  family  health  plus  insurance plans pursuant to this section if
  such employer or other designated sponsor has provided  health  coverage
  during  the  six-month  period  prior  to  application  for  a  group of
  employees. This prohibition shall not apply to:
    (a) an employer or other designated sponsor which employs  fewer  than
  fifty-one  employees  and  has  expenditures for health coverage of more
  than fifteen percent of its payroll;
    (b) a  qualifying  small  employer  or  sole  proprietor  enrolled  in
  insurance coverage pursuant to section forty-three hundred twenty-six of
  the insurance law;
    (c)  an  employer  or  other  designated  sponsor participating in the
  program on or before July first, two thousand ten; or
    (d) an employer  or  other  designated  sponsor  who  entered  into  a
  memorandum  of understanding with the state on or before July first, two
  thousand ten with respect to the purchase of health  insurance  coverage
  under this section for child care providers represented by such sponsor.