S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  3020--A
 
                        2023-2024 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             February 2, 2023
                                ___________
 
 Introduced by M. of A. GONZALEZ-ROJAS, PAULIN, SIMONE, SHRESTHA, ARDILA,
   FORREST,  GALLAGHER,  LEVENBERG,  RAMOS,  RAGA, MITAYNES, LEE, HEVESI,
   SIMON, BURDICK, OTIS, THIELE, TAYLOR, SOLAGES,  BRONSON,  JEAN-PIERRE,
   LAVINE,  HUNTER,  CLARK,  KELLES,  JOYNER,  BICHOTTE HERMELYN, BURGOS,
   EPSTEIN, WEPRIN, CARROLL, L. ROSENTHAL, DINOWITZ, CRUZ,  REYES,  JACK-
   SON,  MAMDANI,  SEAWRIGHT, GLICK, SAYEGH, MEEKS, JACOBSON, KIM, ANDER-
   SON, DAVILA, ZINERMAN, DICKENS, GIBBS,  RIVERA,  DE LOS SANTOS,  McDO-
   NALD,  SHIMSKY,  COLTON,  CUNNINGHAM,  TAPIA, BORES, ALVAREZ, ZACCARO,
   SEPTIMO -- read once and  referred  to  the  Committee  on  Health  --
   reported  and referred to the Committee on Ways and Means -- committee
   discharged, bill amended, ordered reprinted as amended and recommitted
   to said committee
 
 AN ACT to amend the social services law, in  relation  to  coverage  for
   certain individuals under the 1332 state innovation program
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Section 369-ii of the social  services  law,  as  added  by
 section  3  of  part  H of chapter 57 of the laws of 2023, is amended to
 read as follows:
   § 369-ii. 1332 state innovation program. 1. Authorization.    Notwith-
 standing  section  three hundred sixty-nine-gg of this title, subject to
 federal approval, if it is in the financial interest of the state to  do
 so,  the  commissioner of health is authorized, with the approval of the
 director of the budget, to establish a  1332  state  innovation  program
 pursuant  to  section 1332 of the patient protection and affordable care
 act (P.L. 111-148) and subdivision twenty-five of  section  two  hundred
 sixty-eight-c  of  the  public  health law. The commissioner of health's
 authority pursuant to this section  is  contingent  upon  obtaining  and
 maintaining  all  necessary  approvals  from the secretary of health and
 human services and the secretary of the treasury based on an application
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD04552-03-3
 A. 3020--A                          2
              

 
 for a waiver for state innovation.  The  commissioner  of  health  [may]
 SHALL take all actions necessary to obtain such approvals.
   2. Definitions. For the purposes of this section:
   (a)  "Eligible  organization"  means  an  insurer licensed pursuant to
 article thirty-two or forty-two of the insurance law, a  corporation  or
 an  organization  under  article forty-three of the insurance law, or an
 organization certified under article forty-four  of  the  public  health
 law,  including  providers  certified  under  section forty-four hundred
 three-e of the public health law.
   (b) "Approved organization" means an eligible organization approved by
 the commissioner of health to underwrite a 1332 state innovation  health
 insurance plan pursuant to this section.
   (c) "Health care services" means:
   (i) the services and supplies as defined by the commissioner of health
 in consultation with the superintendent of financial services, and shall
 be  consistent  with  and  subject  to  the essential health benefits as
 defined by the commissioner in accordance with  the  provisions  of  the
 patient protection and affordable care act (P.L. 111-148) and consistent
 with the benefits provided by the reference plan selected by the commis-
 sioner  of  health for the purposes of defining such benefits, and shall
 include coverage of and access to the services of  any  national  cancer
 institute-designated  cancer center licensed by the department of health
 within the service area of the approved organization that is willing  to
 agree  to  provide  cancer-related  inpatient,  outpatient  and  medical
 services to all enrollees  in  approved  organizations'  plans  in  such
 cancer  center's  service area under the prevailing terms and conditions
 that the approved organization requires of other similar providers to be
 included in the approved  organization's  network,  provided  that  such
 terms  shall  include  reimbursement  of such center at no less than the
 fee-for-service medicaid payment rate and methodology applicable to  the
 center's inpatient and outpatient services;
   (ii)  dental  and  vision  services  as defined by the commissioner of
 health, and
   (iii) as defined by the commissioner of health and subject to  federal
 approval,  certain  services and supports provided to enrollees who have
 functional limitations and/or chronic illnesses that  have  the  primary
 purpose of supporting the ability of the enrollee to live or work in the
 setting  of  their  choice,  which  may include the individual's home, a
 worksite, or a provider-owned or controlled residential setting.
   (d) "Qualified health plan" means a health plan that meets the  crite-
 ria  for  certification described in § 1311(c) of the patient protection
 and affordable care act (P.L. 111-148), and is  offered  to  individuals
 through  the  NY  State  of  Health, the official health Marketplace, or
 Marketplace, as defined  in  subdivision  two  of  section  two  hundred
 sixty-eight-a of the public health law.
   (e) "Basic health insurance plan" means a health plan providing health
 care  services,  separate and apart from qualified health plans, that is
 issued by an approved organization  and  certified  in  accordance  with
 section three hundred sixty-nine-gg of this title.
   (f)  "1332 state innovation plan" means a standard health plan provid-
 ing health care services, separate and apart  from  a  qualified  health
 plan  and  a  basic health insurance plan, that is issued by an approved
 organization and certified in accordance with this section.
   3. State innovation plan eligible individual. (a) A person is eligible
 to receive coverage for health care under this section if they:
 A. 3020--A                          3
 
   (i) reside in New York state and are under sixty-five  years  of  age,
 INCLUDING  INDIVIDUALS  THAT ARE INELIGIBLE FOR THE BASIC HEALTH PROGRAM
 UNDER 42 U.S.C.  SECTION  18051  ON  THE  BASIS  OF  IMMIGRATION  STATUS
 PROVIDED  THEY  ARE  DETERMINED ELIGIBLE PURSUANT TO SUBDIVISION NINE OF
 THIS  SECTION  AND ARE DETERMINED ELIGIBLE THROUGH THE WAIVER PROCESS TO
 RECEIVE COVERAGE UNDER THIS SECTION REGARDLESS OF DIRECT FEDERAL  FINAN-
 CIAL SUPPORT FOR SUCH INDIVIDUALS;
   (ii)  are  not  eligible  for medical assistance under title eleven of
 this article, EXCLUDING ELIGIBILITY FOR LIMITED MEDICAL  ASSISTANCE  FOR
 THE  TREATMENT  OF AN EMERGENCY MEDICAL CONDITION AUTHORIZED PURSUANT TO
 42 U.S.C. 1396, or for the child  health  insurance  plan  described  in
 title one-A of article twenty-five of the public health law;
   (iii)  are  not eligible for minimum essential coverage, as defined in
 section 5000A(f) of the Internal Revenue Service Code  of  1986,  or  is
 eligible  for  an  employer-sponsored  plan  that  is not affordable, in
 accordance with section 5000A(f) of such code; and
   (iv) have household income at or below two hundred  fifty  percent  of
 the  federal  poverty  line  defined  and annually revised by the United
 States department of health and human services for a  household  of  the
 same  size;  and  has  household income that exceeds one hundred thirty-
 three percent of the federal poverty line defined and  annually  revised
 by  the  United  States  department  of  health and human services for a
 household of the  same  size;  PROVIDED,  however,  THAT  MAGI  eligible
 noncitizens  lawfully present in the United States, AND INDIVIDUALS THAT
 ARE INELIGIBLE FOR THE BASIC HEALTH  PROGRAM  UNDER  42  U.S.C.  SECTION
 18051  ON  THE  BASIS OF IMMIGRATION STATUS with household incomes at or
 below one hundred thirty-three percent of the federal poverty line shall
 be eligible to receive coverage for health care services pursuant to the
 provisions of this section [if such noncitizen would be  ineligible  for
 medical assistance under title eleven of this article due to their immi-
 gration status].
   (b)  Subject to federal approval, a child born to an individual eligi-
 ble for and receiving coverage for health care services pursuant to this
 section who but for their eligibility under this section would be eligi-
 ble for coverage pursuant to subparagraphs two or four of paragraph  (b)
 of  subdivision  one of section three hundred sixty-six of this article,
 shall be administratively enrolled, as defined by  the  commissioner  of
 health,  in  medical assistance and to have been found eligible for such
 assistance on the date of such birth and to  remain  eligible  for  such
 assistance for a period of one year.
   (c) Subject to federal approval, an individual who is eligible for and
 receiving  coverage for health care services pursuant to this section is
 eligible to continue to receive health care services  pursuant  to  this
 section  during  the individual's pregnancy and for a period of one year
 following the end of the pregnancy without regard to any change  in  the
 income  of  the household that includes the pregnant individual, even if
 such change would render the pregnant individual ineligible  to  receive
 health care services pursuant to this section.
   (d)  For  the  purposes of this section, 1332 state innovation program
 eligible individuals are prohibited  from  being  treated  as  qualified
 individuals  under section 1312 of the Affordable Care Act and as eligi-
 ble individuals under section 1331 of the ACA and enrolling in qualified
 health plan through the Marketplace or standard health plan through  the
 Basic Health Program.
   4.  Enrollment.  (a)  Subject to federal approval, the commissioner of
 health is authorized to establish an application and  enrollment  proce-
 A. 3020--A                          4
 
 dure  for prospective enrollees. Such procedure will include a verifica-
 tion system for applicants, which must  be  consistent  with  42  USC  §
 1320b-7.
   (b) Such procedure shall allow for continuous enrollment for enrollees
 to  the  1332 state innovation program where an individual may apply and
 enroll for coverage at any point.
   (c) Upon an applicant's enrollment in a 1332  state  innovation  plan,
 coverage  for  health  care  services pursuant to the provisions of this
 section shall be retroactive to the first day of the month in which  the
 individual  was determined eligible, except in the case of program tran-
 sitions within the Marketplace.
   (d) A person who has enrolled for coverage pursuant to  this  section,
 and who loses eligibility to enroll in the 1332 state innovation program
 for  a  reason other than [citizenship status,] lack of state residence,
 [failure to provide a valid social security number,]  providing  inaccu-
 rate information that would affect eligibility when requesting or renew-
 ing  health  coverage  pursuant  to  this section, or failure to make an
 applicable premium payment, before the end  of  a  twelve  month  period
 beginning  on the effective date of the person's initial eligibility for
 coverage, or before the end of a twelve month period  beginning  on  the
 date  of  any  subsequent determination of eligibility, shall have their
 eligibility for coverage continued until the end of  such  twelve  month
 period,  provided  that  the  state  receives federal approval for using
 funds under an approved 1332 waiver.
   5. Premiums. Subject to federal approval, the commissioner  of  health
 shall  establish  premium  payments enrollees in a 1332 state innovation
 plan shall pay to approved organizations for  coverage  of  health  care
 services pursuant to this section. Such premium payments shall be estab-
 lished in the following manner:
   (a)  up  to fifteen dollars monthly for an individual with a household
 income above two hundred percent of the federal poverty line but  at  or
 below  two hundred fifty percent of the federal poverty line defined and
 annually revised by the United States department  of  health  and  human
 services for a household of the same size; and
   (b)  no payment is required for individuals with a household income at
 or below two hundred percent of the federal  poverty  line  defined  and
 annually  revised  by  the  United States department of health and human
 services for a household of the same size.
   6. Cost-sharing. The commissioner of health shall establish cost-shar-
 ing obligations for enrollees, subject to  federal  approval,  including
 childbirth  and  newborn  care  consistent  with  the medical assistance
 program under title eleven of this article. There shall be no cost-shar-
 ing obligations for enrollees for:
   (a) dental and vision services as  defined  in  subparagraph  (ii)  of
 paragraph (c) of subdivision two of this section; and
   (b)  services  and  supports as defined in subparagraph (iii) of para-
 graph (c) of subdivision two of this section.
   7. Rates of payment. (a) The commissioner of health shall  select  the
 contract  with an independent actuary to study and recommend appropriate
 reimbursement methodologies for the cost of health care service coverage
 pursuant to this section. Such independent actuary shall review and make
 recommendations concerning appropriate actuarial assumptions relevant to
 the establishment of  reimbursement  methodologies,  including  but  not
 limited  to;  the  adequacy of rates of payment in relation to the popu-
 lation to be served adjusted for case mix,  the  scope  of  health  care
 A. 3020--A                          5
 
 services  approved  organizations  must provide, the utilization of such
 services and the network of providers required to meet state standards.
   (b)  Upon  consultation  with  the  independent  actuary  and entities
 representing approved organizations, the commissioner  of  health  shall
 develop  reimbursement  methodologies  and fee schedules for determining
 rates of payment, which rates shall be approved by the director  of  the
 division  of the budget, to be made by the department to approved organ-
 izations for the cost of health care services coverage pursuant to  this
 section.  Such reimbursement methodologies and fee schedules may include
 provisions for capitation arrangements.
   (c) The commissioner of health shall have the authority to  promulgate
 regulations,  including  emergency  regulations, necessary to effectuate
 the provisions of this subdivision.
   (d) The department of health shall  require  the  independent  actuary
 selected  pursuant  to  paragraph  (a)  of this subdivision to provide a
 complete actuarial report, along with all actuarial assumptions made and
 all other data, materials and methodologies used in the  development  of
 rates  for the 1332 state innovation plan authorized under this section.
 Such report shall be provided annually to the temporary president of the
 senate and the speaker of the assembly.
   8. An individual who is lawfully  admitted  for  permanent  residence,
 permanently  residing in the United States under color of law, or who is
 a non-citizen in a valid nonimmigrant status, as  defined  in  8  U.S.C.
 1101(a)(15),  and  who  would be ineligible for medical assistance under
 title eleven of this article due to  their  immigration  status  if  the
 provisions  of  section  one  hundred  twenty-two  of  this chapter were
 applied, shall be considered to be ineligible for medical assistance for
 purposes of paragraphs (b) and (c) of subdivision three of this section.
   9. (A) IN DETERMINING ELIGIBILITY FOR RESIDENTS OF THE STATE THAT  ARE
 INELIGIBLE FOR THE BASIC HEALTH PROGRAM UNDER 42 U.S.C. SECTION 18051 ON
 THE  BASIS  OF  IMMIGRATION STATUS, THE COMMISSIONER OF HEALTH MAY PLACE
 LIMITATIONS ON ENROLLMENT TO  ENSURE  THAT  THE  COSTS  ASSOCIATED  WITH
 RENDERING  SERVICES TO THIS POPULATION DO NOT EXCEED THE REVENUES ANTIC-
 IPATED TO BE TRANSFERRED TO THE  1332  STATE  INNOVATION  PROGRAM  FUND,
 PURSUANT  TO  SECTION NINETY-EIGHT-D OF THE STATE FINANCE LAW. IN ESTAB-
 LISHING ANY LIMITATIONS PURSUANT TO THIS SUBDIVISION THE COMMISSIONER OF
 HEALTH SHALL ENROLL AT LEAST TWO HUNDRED FORTY THOUSAND INDIVIDUALS  AND
 MAY ENROLL ADDITIONAL INDIVIDUALS AS REASONABLY PRACTICABLE WHILE ENSUR-
 ING  CONTINUAL COVERAGE FOR SUCH ADDITIONAL INDIVIDUALS BASED ON CURRENT
 AND ANTICIPATED 1332 STATE INNOVATION PROGRAM FUND RESERVES.
   (B) IN DETERMINING ANY LIMITATIONS ON ENROLLMENT, THE COMMISSIONER  OF
 HEALTH  SHALL  DETERMINE  INCOME BANDS FOR SUCH INDIVIDUALS FROM ZERO TO
 TWO HUNDRED FIFTY PERCENT OF THE FEDERAL POVERTY LINE DEFINED AND  ANNU-
 ALLY  REVISED  BY  THE  UNITED  STATES  DEPARTMENT  OF  HEALTH AND HUMAN
 SERVICES FOR A HOUSEHOLD OF THE SAME SIZE. THE  COMMISSIONER  OF  HEALTH
 SHALL  PRIORITIZE  THE  ENROLLMENT OF INDIVIDUALS FROM THE LOWEST INCOME
 BAND FIRST AND THEN THE REMAINING INCOME BANDS IN ASCENDING ORDER.
   (C) NOTWITHSTANDING THE PROVISIONS OF PARAGRAPH (B) OF  THIS  SUBDIVI-
 SION,  THE  COMMISSIONER OF HEALTH MAY ALSO INCLUDE SUBSETS OF THE POPU-
 LATION WHOSE CONTINUED HEALTH AND WELL-BEING WOULD BE  SIGNIFICANTLY  AT
 RISK  WITHOUT  ROUTINE  ACCESS  TO HEALTH CARE. POPULATION SUBSETS TO BE
 PRIORITIZED FOR ENROLLMENT SHALL BE DETERMINED BY  THE  COMMISSIONER  OF
 HEALTH  AND  SHALL  INCLUDE  BUT NOT BE LIMITED TO: (I) INDIVIDUALS WITH
 LIFE THREATENING CONDITIONS, (II) INDIVIDUALS IN NEED OF AN ORGAN TRANS-
 PLANT; AND (III) INDIVIDUALS WITH SIGNIFICANT BEHAVIORAL  HEALTH  ISSUES
 A. 3020--A                          6

 INCLUDING  BUT  NOT  LIMITED  TO SERIOUS MENTAL ILLNESS OR SUBSTANCE USE
 DISORDER.
   10.  THE  COMMISSIONER  OF  HEALTH SHALL TAKE ALL ACTIONS NECESSARY TO
 OBTAIN ALL NECESSARY  APPROVALS  FROM THE SECRETARY OF HEALTH AND  HUMAN
 SERVICES AND THE SECRETARY OF THE TREASURY TO UTILIZE MONEYS TRANSFERRED
 TO  THE BASIC HEALTH PROGRAM TRUST FUND, PURSUANT TO SECTION NINETY-SEV-
 EN-OOOO OF THE STATE FINANCE LAW, AS ADDED  BY  SECTION  FIFTY-THREE  OF
 PART  C OF CHAPTER SIXTY OF THE LAWS OF TWO THOUSAND FOURTEEN, FOR COSTS
 ASSOCIATED WITH THE PROVISION OF HEALTH CARE  SERVICES  TO  ALL  PERSONS
 ELIGIBLE  FOR  COVERAGE UNDER THE WAIVER. IF APPROVAL IS NOT GRANTED FOR
 ALL PERSONS ELIGIBLE FOR COVERAGE UNDER THE WAIVER, THE COMMISSIONER  OF
 HEALTH  SHALL  TAKE ALL ACTIONS NECESSARY TO OBTAIN APPROVAL FOR THE USE
 OF MONEYS OF THE BASIC HEALTH PROGRAM TRUST FUND  FOR  COSTS  ASSOCIATED
 WITH  THE  PROVISION  OF  HEALTH  CARE SERVICES TO INDIVIDUALS UNDER THE
 WAIVER THAT WOULD OTHERWISE BE ELIGIBLE FOR PARTICIPATION IN  THE  BASIC
 HEALTH  PROGRAM,  ESTABLISHED  PURSUANT  TO SECTION THREE HUNDRED SIXTY-
 NINE-GG OF THIS TITLE.
   11. Reporting. The commissioner of health shall submit a report to the
 temporary president of the senate and the speaker of the assembly  annu-
 ally  by  December thirty-first. The report shall include, at a minimum,
 an analysis of the 1332 state innovation program and its impact  on  the
 financial interest of the state; its impact on the Marketplace including
 enrollment  and premiums; its impact on the number of uninsured individ-
 uals in the state; its impact on the Medicaid global cap; ANY ENROLLMENT
 LIMITATIONS ESTABLISHED PURSUANT TO SUBDIVISION  NINE  OF  THIS  SECTION
 INCLUDING  THE  RATIONALE  AND  SUPPORTING  FISCAL  CALCULATIONS USED TO
 JUSTIFY SUCH LIMITATION, INCLUDING ANY HISTORICAL  DATA,  IF  AVAILABLE,
 FOR  THE  PREVIOUS  THREE  YEARS  RELATED TO ANY PREVIOUS LIMITATIONS OF
 ENROLLMENT, FUNDS TRANSFERRED TO THE 1332 STATE INNOVATION PROGRAM  FUND
 PURSUANT  TO SECTION NINETY-EIGHT-D OF THE STATE FINANCE LAW, AND TOTALS
 ON ANY SAVINGS TO THE STATE DUE TO COVERAGE OF RESIDENTS  OF  THE  STATE
 THAT ARE INELIGIBLE FOR THE BASIC HEALTH PROGRAM UNDER 42 U.S.C. SECTION
 18051  ON  THE BASIS OF IMMIGRATION STATUS; ANY MONEYS UTILIZED FROM THE
 BASIC HEALTH PLAN TRUST FUND TO SUPPORT  THE  DELIVERY  OF  HEALTH  CARE
 SERVICES  TO  PERSONS  ELIGIBLE  FOR  COVERAGE UNDER THE WAIVER; and the
 demographics of the 1332 state innovation  program  enrollees  including
 age and immigration status.
   [10.]  12. Severability. If the secretary of health and human services
 or the secretary of the treasury do not approve  any  provision  of  the
 application for a state innovation waiver, such decision shall in no way
 affect  or  impair any other provisions that the secretaries may approve
 under this section.
   § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
 sion, section or part of this act shall be  adjudged  by  any  court  of
 competent  jurisdiction  to  be invalid, such judgment shall not affect,
 impair, or invalidate the remainder thereof, but shall  be  confined  in
 its  operation  to the clause, sentence, paragraph, subdivision, section
 or part thereof directly involved in the controversy in which such judg-
 ment shall have been rendered. It is hereby declared to be the intent of
 the legislature that this act would  have  been  enacted  even  if  such
 invalid provisions had not been included herein.
   §  3.  This  act  shall  take  effect on the same date and in the same
 manner as section 3 of part H of chapter 57 of the laws of 2023 amending
 the social services law relating to enacting the 1332  state  innovation
 program, takes effect.

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  3020--B
 
                        2023-2024 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             February 2, 2023
                                ___________
 
 Introduced by M. of A. GONZALEZ-ROJAS, PAULIN, SIMONE, SHRESTHA, ARDILA,
   FORREST,  GALLAGHER,  LEVENBERG,  RAMOS,  RAGA, MITAYNES, LEE, HEVESI,
   SIMON, BURDICK, OTIS, THIELE, TAYLOR, SOLAGES,  BRONSON,  JEAN-PIERRE,
   LAVINE,  CLARK,  KELLES,  JOYNER,  BICHOTTE HERMELYN, BURGOS, EPSTEIN,
   WEPRIN, CARROLL, L. ROSENTHAL, DINOWITZ, CRUZ, REYES, JACKSON,  MAMDA-
   NI,  SEAWRIGHT,  GLICK, MEEKS, JACOBSON, KIM, ANDERSON, DAVILA, ZINER-
   MAN, DICKENS, GIBBS, RIVERA, DE LOS SANTOS, SHIMSKY, COLTON,  CUNNING-
   HAM,  TAPIA,  BORES,  ALVAREZ,  ZACCARO,  SEPTIMO,  CHANDLER-WATERMAN,
   LUCAS, DILAN, COOK -- read once  and  referred  to  the  Committee  on
   Health  -- reported and referred to the Committee on Ways and Means --
   committee discharged, bill amended, ordered reprinted as  amended  and
   recommitted  to  said committee -- committee discharged, bill amended,
   ordered reprinted as amended and recommitted to said committee
 
 AN ACT to amend the social services law, in  relation  to  coverage  for
   certain individuals under the 1332 state innovation program
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:

   Section 1. Section 369-ii of the social  services  law,  as  added  by
 section  3  of  part  H of chapter 57 of the laws of 2023, is amended to
 read as follows:
   § 369-ii. 1332 state innovation program. 1. Authorization.    Notwith-
 standing  section  three hundred sixty-nine-gg of this title, subject to
 federal approval, if it is in the financial interest of the state to  do
 so,  the  commissioner of health is authorized, with the approval of the
 director of the budget, to establish a  1332  state  innovation  program
 pursuant  to  section 1332 of the patient protection and affordable care
 act (P.L. 111-148) and subdivision twenty-five of  section  two  hundred
 sixty-eight-c  of  the  public  health law. The commissioner of health's
 authority pursuant to this section  is  contingent  upon  obtaining  and
 maintaining  all  necessary  approvals  from the secretary of health and
 human services and the secretary of the treasury based on an application
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD04552-07-3
              

 A. 3020--B                          2
 
 for a waiver for state innovation.  The  commissioner  of  health  [may]
 SHALL  take  all  actions  necessary to obtain such approvals, INCLUDING
 SEEKING ANY NECESSARY APPROVALS FOR AMENDMENTS TO THE WAIVER.
   2. Definitions. For the purposes of this section:
   (a)  "Eligible  organization"  means  an  insurer licensed pursuant to
 article thirty-two or forty-two of the insurance law, a  corporation  or
 an  organization  under  article forty-three of the insurance law, or an
 organization certified under article forty-four  of  the  public  health
 law,  including  providers  certified  under  section forty-four hundred
 three-e of the public health law.
   (b) "Approved organization" means an eligible organization approved by
 the commissioner of health to underwrite a 1332 state innovation  health
 insurance plan pursuant to this section.
   (c) "Health care services" means:
   (i) the services and supplies as defined by the commissioner of health
 in consultation with the superintendent of financial services, and shall
 be  consistent  with  and  subject  to  the essential health benefits as
 defined by the commissioner in accordance with  the  provisions  of  the
 patient protection and affordable care act (P.L. 111-148) and consistent
 with the benefits provided by the reference plan selected by the commis-
 sioner  of  health for the purposes of defining such benefits, and shall
 include coverage of and access to the services of  any  national  cancer
 institute-designated  cancer center licensed by the department of health
 within the service area of the approved organization that is willing  to
 agree  to  provide  cancer-related  inpatient,  outpatient  and  medical
 services to all enrollees  in  approved  organizations'  plans  in  such
 cancer  center's  service area under the prevailing terms and conditions
 that the approved organization requires of other similar providers to be
 included in the approved  organization's  network,  provided  that  such
 terms  shall  include  reimbursement  of such center at no less than the
 fee-for-service medicaid payment rate and methodology applicable to  the
 center's inpatient and outpatient services;
   (ii)  dental  and  vision  services  as defined by the commissioner of
 health, and
   (iii) as defined by the commissioner of health and subject to  federal
 approval,  certain  services and supports provided to enrollees who have
 functional limitations and/or chronic illnesses that  have  the  primary
 purpose of supporting the ability of the enrollee to live or work in the
 setting  of  their  choice,  which  may include the individual's home, a
 worksite, or a provider-owned or controlled residential setting.
   (d) "Qualified health plan" means a health plan that meets the  crite-
 ria  for  certification described in § 1311(c) of the patient protection
 and affordable care act (P.L. 111-148), and is  offered  to  individuals
 through  the  NY  State  of  Health, the official health Marketplace, or
 Marketplace, as defined  in  subdivision  two  of  section  two  hundred
 sixty-eight-a of the public health law.
   (e) "Basic health insurance plan" means a health plan providing health
 care  services,  separate and apart from qualified health plans, that is
 issued by an approved organization  and  certified  in  accordance  with
 section three hundred sixty-nine-gg of this title.
   (f)  "1332 state innovation plan" means a standard health plan provid-
 ing health care services, separate and apart  from  a  qualified  health
 plan  and  a  basic health insurance plan, that is issued by an approved
 organization and certified in accordance with this section.
   3. State innovation plan eligible individual. (a) A person is eligible
 to receive coverage for health care under this section if they:
 A. 3020--B                          3
 
   (i) reside in New York state and are under sixty-five  years  of  age,
 INCLUDING  INDIVIDUALS  THAT ARE INELIGIBLE FOR THE BASIC HEALTH PROGRAM
 UNDER 42 U.S.C.  SECTION  18051  ON  THE  BASIS  OF  IMMIGRATION  STATUS
 PROVIDED  THEY  ARE  DETERMINED ELIGIBLE PURSUANT TO SUBDIVISION NINE OF
 THIS  SECTION  AND ARE DETERMINED ELIGIBLE THROUGH THE WAIVER PROCESS TO
 RECEIVE COVERAGE UNDER THIS SECTION REGARDLESS OF DIRECT FEDERAL  FINAN-
 CIAL SUPPORT FOR SUCH INDIVIDUALS;
   (ii)  are  not  eligible  for medical assistance under title eleven of
 this article, EXCLUDING ELIGIBILITY FOR LIMITED MEDICAL  ASSISTANCE  FOR
 THE  TREATMENT  OF AN EMERGENCY MEDICAL CONDITION AUTHORIZED PURSUANT TO
 42 U.S.C. 1396, or for the child  health  insurance  plan  described  in
 title one-A of article twenty-five of the public health law;
   (iii)  are  not eligible for minimum essential coverage, as defined in
 section 5000A(f) of the Internal Revenue Service Code  of  1986,  or  is
 eligible  for  an  employer-sponsored  plan  that  is not affordable, in
 accordance with section 5000A(f) of such code; and
   (iv) have household income at or below two hundred  fifty  percent  of
 the  federal  poverty  line  defined  and annually revised by the United
 States department of health and human services for a  household  of  the
 same  size;  and  has  household income that exceeds one hundred thirty-
 three percent of the federal poverty line defined and  annually  revised
 by  the  United  States  department  of  health and human services for a
 household of the  same  size;  PROVIDED,  however,  THAT  MAGI  eligible
 noncitizens  lawfully present in the United States, AND INDIVIDUALS THAT
 ARE INELIGIBLE FOR THE BASIC HEALTH  PROGRAM  UNDER  42  U.S.C.  SECTION
 18051  ON  THE  BASIS OF IMMIGRATION STATUS with household incomes at or
 below one hundred thirty-three percent of the federal poverty line shall
 be eligible to receive coverage for health care services pursuant to the
 provisions of this section [if such noncitizen would be  ineligible  for
 medical assistance under title eleven of this article due to their immi-
 gration status].
   (b)  Subject to federal approval, a child born to an individual eligi-
 ble for and receiving coverage for health care services pursuant to this
 section who but for their eligibility under this section would be eligi-
 ble for coverage pursuant to subparagraphs two or four of paragraph  (b)
 of  subdivision  one of section three hundred sixty-six of this article,
 shall be administratively enrolled, as defined by  the  commissioner  of
 health,  in  medical assistance and to have been found eligible for such
 assistance on the date of such birth and to  remain  eligible  for  such
 assistance for a period of one year.
   (c) Subject to federal approval, an individual who is eligible for and
 receiving  coverage for health care services pursuant to this section is
 eligible to continue to receive health care services  pursuant  to  this
 section  during  the individual's pregnancy and for a period of one year
 following the end of the pregnancy without regard to any change  in  the
 income  of  the household that includes the pregnant individual, even if
 such change would render the pregnant individual ineligible  to  receive
 health care services pursuant to this section.
   (d)  For  the  purposes of this section, 1332 state innovation program
 eligible individuals are prohibited  from  being  treated  as  qualified
 individuals  under section 1312 of the Affordable Care Act and as eligi-
 ble individuals under section 1331 of the ACA and enrolling in qualified
 health plan through the Marketplace or standard health plan through  the
 Basic Health Program.
   4.  Enrollment.  (a)  Subject to federal approval, the commissioner of
 health is authorized to establish an application and  enrollment  proce-
 A. 3020--B                          4
 
 dure  for prospective enrollees. Such procedure will include a verifica-
 tion system for applicants, which must  be  consistent  with  42  USC  §
 1320b-7.
   (b) Such procedure shall allow for continuous enrollment for enrollees
 to  the  1332 state innovation program where an individual may apply and
 enroll for coverage at any point.
   (c) Upon an applicant's enrollment in a 1332  state  innovation  plan,
 coverage  for  health  care  services pursuant to the provisions of this
 section shall be retroactive to the first day of the month in which  the
 individual  was determined eligible, except in the case of program tran-
 sitions within the Marketplace.
   (d) A person who has enrolled for coverage pursuant to  this  section,
 and who loses eligibility to enroll in the 1332 state innovation program
 for  a  reason other than [citizenship status,] lack of state residence,
 [failure to provide a valid social security number,]  providing  inaccu-
 rate information that would affect eligibility when requesting or renew-
 ing  health  coverage  pursuant  to  this section, or failure to make an
 applicable premium payment, before the end  of  a  twelve  month  period
 beginning  on the effective date of the person's initial eligibility for
 coverage, or before the end of a twelve month period  beginning  on  the
 date  of  any  subsequent determination of eligibility, shall have their
 eligibility for coverage continued until the end of  such  twelve  month
 period,  provided  that  the  state  receives federal approval for using
 funds under an approved 1332 waiver.
   5. Premiums. Subject to federal approval, the commissioner  of  health
 shall  establish  premium  payments enrollees in a 1332 state innovation
 plan shall pay to approved organizations for  coverage  of  health  care
 services pursuant to this section. Such premium payments shall be estab-
 lished in the following manner:
   (a)  up  to fifteen dollars monthly for an individual with a household
 income above two hundred percent of the federal poverty line but  at  or
 below  two hundred fifty percent of the federal poverty line defined and
 annually revised by the United States department  of  health  and  human
 services for a household of the same size; and
   (b)  no payment is required for individuals with a household income at
 or below two hundred percent of the federal  poverty  line  defined  and
 annually  revised  by  the  United States department of health and human
 services for a household of the same size.
   6. Cost-sharing. The commissioner of health shall establish cost-shar-
 ing obligations for enrollees, subject to  federal  approval,  including
 childbirth  and  newborn  care  consistent  with  the medical assistance
 program under title eleven of this article. There shall be no cost-shar-
 ing obligations for enrollees for:
   (a) dental and vision services as  defined  in  subparagraph  (ii)  of
 paragraph (c) of subdivision two of this section; and
   (b)  services  and  supports as defined in subparagraph (iii) of para-
 graph (c) of subdivision two of this section.
   7. Rates of payment. (a) The commissioner of health shall  select  the
 contract  with an independent actuary to study and recommend appropriate
 reimbursement methodologies for the cost of health care service coverage
 pursuant to this section. Such independent actuary shall review and make
 recommendations concerning appropriate actuarial assumptions relevant to
 the establishment of  reimbursement  methodologies,  including  but  not
 limited  to;  the  adequacy of rates of payment in relation to the popu-
 lation to be served adjusted for case mix,  the  scope  of  health  care
 A. 3020--B                          5
 
 services  approved  organizations  must provide, the utilization of such
 services and the network of providers required to meet state standards.
   (b)  Upon  consultation  with  the  independent  actuary  and entities
 representing approved organizations, the commissioner  of  health  shall
 develop  reimbursement  methodologies  and fee schedules for determining
 rates of payment, which rates shall be approved by the director  of  the
 division  of the budget, to be made by the department to approved organ-
 izations for the cost of health care services coverage pursuant to  this
 section.  Such reimbursement methodologies and fee schedules may include
 provisions for capitation arrangements.
   (c) The commissioner of health shall have the authority to  promulgate
 regulations,  including  emergency  regulations, necessary to effectuate
 the provisions of this subdivision.
   (d) The department of health shall  require  the  independent  actuary
 selected  pursuant  to  paragraph  (a)  of this subdivision to provide a
 complete actuarial report, along with all actuarial assumptions made and
 all other data, materials and methodologies used in the  development  of
 rates  for the 1332 state innovation plan authorized under this section.
 Such report shall be provided annually to the temporary president of the
 senate and the speaker of the assembly.
   8. An individual who is lawfully  admitted  for  permanent  residence,
 permanently  residing in the United States under color of law, or who is
 a non-citizen in a valid nonimmigrant status, as  defined  in  8  U.S.C.
 1101(a)(15),  and  who  would be ineligible for medical assistance under
 title eleven of this article due to  their  immigration  status  if  the
 provisions  of  section  one  hundred  twenty-two  of  this chapter were
 applied, shall be considered to be ineligible for medical assistance for
 purposes of paragraphs (b) and (c) of subdivision three of this section.
   9. (A) IN DETERMINING ELIGIBILITY FOR RESIDENTS OF THE STATE THAT  ARE
 INELIGIBLE FOR THE BASIC HEALTH PROGRAM UNDER 42 U.S.C. SECTION 18051 ON
 THE  BASIS  OF  IMMIGRATION STATUS, THE COMMISSIONER OF HEALTH MAY PLACE
 LIMITATIONS ON ENROLLMENT TO  ENSURE  THAT  THE  COSTS  ASSOCIATED  WITH
 RENDERING  SERVICES TO THIS POPULATION DO NOT EXCEED THE REVENUES ANTIC-
 IPATED TO BE TRANSFERRED TO THE  1332  STATE  INNOVATION  PROGRAM  FUND,
 PURSUANT  TO  SECTION NINETY-EIGHT-D OF THE STATE FINANCE LAW. IN ESTAB-
 LISHING ANY LIMITATIONS PURSUANT TO THIS SUBDIVISION THE COMMISSIONER OF
 HEALTH SHALL ENROLL AS MANY INDIVIDUALS AS REASONABLY PRACTICABLE  WHILE
 ENSURING  CONTINUAL  COVERAGE  FOR  SUCH ADDITIONAL INDIVIDUALS BASED ON
 CURRENT AND ANTICIPATED 1332 STATE INNOVATION PROGRAM FUND RESERVES.
   (B) IN DETERMINING ANY LIMITATIONS ON ENROLLMENT, THE COMMISSIONER  OF
 HEALTH  SHALL  DETERMINE  INCOME BANDS FOR SUCH INDIVIDUALS FROM ZERO TO
 TWO HUNDRED FIFTY PERCENT OF THE FEDERAL POVERTY LINE DEFINED AND  ANNU-
 ALLY  REVISED  BY  THE  UNITED  STATES  DEPARTMENT  OF  HEALTH AND HUMAN
 SERVICES FOR A HOUSEHOLD OF THE SAME SIZE. THE  COMMISSIONER  OF  HEALTH
 SHALL  PRIORITIZE  THE  ENROLLMENT OF INDIVIDUALS FROM THE LOWEST INCOME
 BAND FIRST AND THEN THE REMAINING INCOME BANDS IN ASCENDING ORDER.
   (C) NOTWITHSTANDING THE PROVISIONS OF PARAGRAPH (B) OF  THIS  SUBDIVI-
 SION,  THE  COMMISSIONER OF HEALTH MAY ALSO INCLUDE SUBSETS OF THE POPU-
 LATION WHOSE CONTINUED HEALTH AND WELL-BEING WOULD BE  SIGNIFICANTLY  AT
 RISK  WITHOUT  ROUTINE  ACCESS  TO HEALTH CARE. POPULATION SUBSETS TO BE
 PRIORITIZED FOR ENROLLMENT SHALL BE DETERMINED BY  THE  COMMISSIONER  OF
 HEALTH  AND  SHALL  INCLUDE  BUT NOT BE LIMITED TO: (I) INDIVIDUALS WITH
 LIFE THREATENING CONDITIONS, (II) INDIVIDUALS IN NEED OF AN ORGAN TRANS-
 PLANT; AND (III) INDIVIDUALS WITH SIGNIFICANT BEHAVIORAL  HEALTH  ISSUES
 INCLUDING  BUT  NOT  LIMITED  TO SERIOUS MENTAL ILLNESS OR SUBSTANCE USE
 DISORDER.
 A. 3020--B                          6
 
   10. THE COMMISSIONER IS AUTHORIZED TO SEEK A WAIVER OR OTHER  APPLICA-
 BLE FEDERAL APPROVAL FOR ANY ADDITIONAL MONIES TO SUPPORT THE 1332 STATE
 INNOVATION PROGRAM THAT MAY BE ASSOCIATED WITH A REDUCTION IN THE UTILI-
 ZATION OF TREATMENT FOR AN EMERGENCY MEDICAL CONDITION AUTHORIZED PURSU-
 ANT TO 42 U.S.C. 1396. ANY ADDITIONAL MONIES SHALL BE TRANSFERRED TO THE
 1332 STATE INNOVATION PROGRAM FUND ESTABLISHED PURSUANT TO SECTION NINE-
 TY-EIGHT-D OF THE STATE FINANCE LAW AND USED FOR SUCH PURPOSES.
   11. Reporting. The commissioner of health shall submit a report to the
 temporary  president of the senate and the speaker of the assembly annu-
 ally by December thirty-first. The report shall include, at  a  minimum,
 an  analysis  of the 1332 state innovation program and its impact on the
 financial interest of the state; its impact on the Marketplace including
 enrollment and premiums; its impact on the number of uninsured  individ-
 uals in the state; its impact on the Medicaid global cap; ANY ENROLLMENT
 LIMITATIONS  ESTABLISHED  PURSUANT  TO  SUBDIVISION NINE OF THIS SECTION
 INCLUDING THE RATIONALE  AND  SUPPORTING  FISCAL  CALCULATIONS  USED  TO
 JUSTIFY  SUCH  LIMITATION,  INCLUDING ANY HISTORICAL DATA, IF AVAILABLE,
 FOR THE PREVIOUS THREE YEARS RELATED  TO  ANY  PREVIOUS  LIMITATIONS  OF
 ENROLLMENT,  FUNDS TRANSFERRED TO THE 1332 STATE INNOVATION PROGRAM FUND
 PURSUANT TO SECTION NINETY-EIGHT-D OF THE STATE FINANCE LAW, AND  TOTALS
 ON  ANY  SAVINGS  TO THE STATE DUE TO COVERAGE OF RESIDENTS OF THE STATE
 THAT ARE INELIGIBLE FOR THE BASIC HEALTH PROGRAM UNDER 42 U.S.C. SECTION
 18051 ON THE BASIS OF IMMIGRATION STATUS; and the  demographics  of  the
 1332  state  innovation  program enrollees including age and immigration
 status.
   [10.] 12. Severability. If the secretary of health and human  services
 or  the  secretary  of  the treasury do not approve any provision of the
 application for a state innovation waiver, such decision shall in no way
 affect or impair any other provisions that the secretaries  may  approve
 under this section.
   § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
 sion,  section  or  part  of  this act shall be adjudged by any court of
 competent jurisdiction to be invalid, such judgment  shall  not  affect,
 impair,  or  invalidate  the remainder thereof, but shall be confined in
 its operation to the clause, sentence, paragraph,  subdivision,  section
 or part thereof directly involved in the controversy in which such judg-
 ment shall have been rendered. It is hereby declared to be the intent of
 the  legislature  that  this  act  would  have been enacted even if such
 invalid provisions had not been included herein.
   § 3. This act shall take effect on the  same  date  and  in  the  same
 manner  as  section 3 of part H of chapter 57 of the laws of 2023, takes
 effect.