S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1710
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 14, 2025
                                ___________
 
 Introduced  by  M.  of  A.  GONZALEZ-ROJAS, PAULIN, GALLAGHER, MITAYNES,
   OTIS,  KELLES,  SIMONE,  LEVENBERG,  LEE,  TAYLOR,  BICHOTTE HERMELYN,
   SHRESTHA,  RAMOS,  HEVESI,  BRONSON,  EPSTEIN,  FORREST,  RAGA, SIMON,
   BURDICK, CLARK, WEPRIN, CRUZ, R. CARROLL, ROSENTHAL, DINOWITZ,  REYES,
   JACKSON,  MAMDANI,  SEAWRIGHT,  GLICK, MEEKS, JACOBSON, KIM, ANDERSON,
   DAVILA, ZINERMAN, GIBBS, RIVERA, DE LOS SANTOS,  SHIMSKY,  CUNNINGHAM,
   TAPIA,  BORES,  ALVAREZ,  ZACCARO,  SEPTIMO, CHANDLER-WATERMAN, LUCAS,
   COOK, DILAN -- read once and referred to the Committee on Health
 
 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
 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:

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD00653-01-5
 A. 1710                             2
              

 
   (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:
   (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
 A. 1710                             3
 
 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-
 dure  for prospective enrollees. Such procedure will include a verifica-
 tion system for applicants, which must  be  consistent  with  42  USC  §
 1320b-7.
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   (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
 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
 A. 1710                             5
 
 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.
   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-
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 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.