§ 2511. Child health insurance plan 1. (a) The commissioner, in
consultation with the superintendent, shall establish a program to the
extent of funds available therefor through contractual arrangements with
approved organizations to provide covered health care services coverage
for eligible children. The availability of coverage for primary and
preventive health care services and inpatient health care services
coverage shall be continued pending approval of contractual arrangements
that include covered health care services coverage and implementation of
such coverage to the extent of funds available therefor.

(b) Coverage for covered health care services shall not be effective
until such time as contractual arrangements are executed pursuant to
this section for such purposes and an eligible child is enrolled in the
program.

2. In order to be eligible for a subsidy payment pursuant to
subdivision three of this section, a child shall meet the following
criteria:

(a) (i) effective January first, nineteen hundred ninety-nine, resides
in a household having a net household income at or below one hundred
ninety-two percent of the non-farm federal poverty level (as defined and
updated by the United States department of health and human services) or
the gross equivalent of such net income; and

(ii) effective July first, two thousand, resides in a household having
a gross household income at or below two hundred fifty percent of the
non-farm federal poverty level (as defined and updated by the United
States department of health and human services); and

(iii) effective September first, two thousand eight, resides in a
household having a household income at or below four hundred percent of
the non-farm federal poverty level (as defined and updated by the United
States department of health and human services);

(b) is not eligible for medical assistance, except that a child who
becomes eligible for medical assistance after becoming an eligible child
under this title, may be eligible for a subsidy payment pursuant to
subdivision three of this section as medical assistance for a period up
to three months after becoming eligible for medical assistance; and

(c) does not have health care coverage under insurance, as defined by
the commissioner, in consultation with the superintendent. The applicant
for insurance shall attest to the source and nature of the child's
health care coverage under this paragraph, if any; and

* (e) is a resident of New York state. Such residency shall be
demonstrated by adequate proof, as determined by the commissioner, of a
New York state street address. If the child has no street address, such
proof may include, but not be limited to, school records or other
documentation determined by the commissioner.

* NB Effective until January 1, 2014 or a later date to be determined
by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (e) is a resident of New York state. Such residency shall be
attested to by the applicant for insurance, provided however, the
commissioner shall require adequate proof of a New York state street
address in circumstances when there is an inconsistency with residency
information from other data sources.

* NB Effective January 1, 2014 or a later date to be determined by the
commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

(f) * (i) In order to establish income eligibility under this
subdivision at initial application, a household shall provide such
documentation specified in subparagraph (iii) of this paragraph, as
necessary and sufficient to determine a child's financial eligibility
for a subsidy payment under this title. The commissioner may verify the
accuracy of such income information provided by the household by
matching it against income information contained in databases to which
the commissioner has access, including the state's wage reporting system
pursuant to subdivision five of section one hundred seventy-one-a of the
tax law and by means of an income verification performed pursuant to a
cooperative agreement with the department of taxation and finance
pursuant to subdivision four of section one hundred seventy-one-b of the
tax law.

* NB Effective until January 1, 2014 or a later date to be determined
by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (i) In order to establish income eligibility under this subdivision
at initial application, a household shall provide the social security
numbers for each parent and legally responsible adult who is a member of
the household, subject to subparagraph (v) of this paragraph. The
commissioner shall determine eligibility based on income information
contained in databases to which the commissioner has access, including
the state's wage reporting system pursuant to subdivision five of
section one hundred seventy-one-a of the tax law and by means of an
income verification performed pursuant to a cooperative agreement with
the department of taxation and finance pursuant to subdivision four of
section one hundred seventy-one-b of the tax law. The commissioner shall
require an attestation by the household that the income information
obtained from electronic data sources is accurate. Such attestation
shall include any other household income information not obtained from
an electronic data source that is necessary to determine a child's
financial eligibility for a subsidy payment under this title. If the
attestation is reasonably compatible with information obtained from
available data sources, no further information or documentation is
required. If the attestation is not reasonably compatible with
information obtained from available data sources, documentation shall be
required as specified in subparagraph (iii) of this paragraph.

* NB Effective January 1, 2014 or a later date to be determined by the
commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

(ii) In order to establish income eligibility under this subdivision
at recertification, the commissioner may make a redetermination of
eligibility without requiring information from the individual if able to
do so based on reliable information contained in the individual's
enrollment file or other more current information contained in databases
to which the commissioner has access, including the state's wage
reporting system and by means of an income verification performed
pursuant to a cooperative agreement with the department of taxation and
finance pursuant to subdivision four of section one hundred
seventy-one-b of the tax law. The commissioner shall require an
attestation by the household that the income information contained in
the enrollment file or obtained from electronic data sources is
accurate. Such attestation shall include any other household income
information not obtained from an electronic data source that is
necessary to redetermine a child's financial eligibility for a subsidy
payment under this title. In the event that there is an inconsistency
between the income information attested to by the household and any
information obtained by the commissioner from other sources pursuant to
this subparagraph, and such inconsistency is material to the household's
eligibility for a subsidy payment under this title, the commissioner
shall require the household to provide income documentation as specified
in subparagraph (iii) of this paragraph.

* (iii) Income documentation shall include, but not be limited to, one
or more of the following for each parent and legally responsible adult
who is a member of the household and whose income is available to the
child;

(A) current annual income tax returns;

(B) paycheck stubs;

(C) written documentation of income from all employers; or

(D) written documentation of income eligibility of a child for free or
reduced breakfast or lunch through the school meal program certified by
the child's school, provided that:

(I) the commissioner may verify the accuracy of the information
provided in the same manner and way as provided for in subparagraph (ii)
of this paragraph; and

(II) such documentation may not be suitable proof of income in the
event of a material inconsistency in income after the commissioner has
performed verification pursuant to subparagraph (ii) of this paragraph;
or

(E) other documentation of income (earned or unearned) as determined
by the commissioner, provided, however, such documentation shall set
forth the source of such income.

* NB Effective until January 1, 2014 or a later date to be determined
by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (iii) If the attestation of household income required by
subparagraphs (i) and (ii) of this paragraph is not reasonably
compatible with information obtained from data sources, further
information, including documentation, shall be required. Income
documentation shall include, but not be limited to, one or more of the
following for each parent and legally responsible adult who is a member
of the household and whose income is available to the child;

(A) current annual income tax returns;

(B) paycheck stubs;

(C) written documentation of income from all employers; or

(D) written documentation of income eligibility of a child for free or
reduced breakfast or lunch through the school meal program certified by
the child's school, provided that:

(I) the commissioner may verify the accuracy of the information
provided in the same manner and way as provided for in subparagraph (ii)
of this paragraph; and

(II) such documentation may not be suitable proof of income in the
event of a material inconsistency in income after the commissioner has
performed verification pursuant to subparagraph (ii) of this paragraph;
or

(E) other documentation of income (earned or unearned) as determined
by the commissioner, provided, however, such documentation shall set
forth the source of such income.

* NB Effective January 1, 2014 or a later date to be determined by the
commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (iv) In the event a household does not provide income documentation
required by subparagraph (iii) of this paragraph within two months of
the approved organization's request, the approved organization shall
disenroll the child at the end of such two month period. Except as
provided in paragraph (c) of subdivision five-a of this section,
approved organizations shall not be obligated to repay subsidy payments
made by the state on behalf of children enrolled during this two month
period.

* NB Effective until January 1, 2014 or a later date to be determined
by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (iv) In the event a household does not provide income documentation
required by subparagraph (iii) of this paragraph within two months of
the approved organization's or state enrollment center's request,
whichever is applicable, the approved organization or state enrollment
center shall disenroll the child at the end of such two month period.
Except as provided in paragraph (c) of subdivision five-a of this
section, approved organizations shall not be obligated to repay subsidy
payments made by the state on behalf of children enrolled during this
two month period.

* NB Effective January 1, 2014 or a later date to be determined by the
commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (v) In the event a household chooses not to provide the social
security numbers required by subparagraph (ii) of this paragraph, such
household shall provide income documentation specified in subparagraph
(iii) of this paragraph as a condition of the child's enrollment.
Nothing in this paragraph shall be construed as obligating a household
to provide social security numbers of parents or legally responsible
adults as a condition of a child's enrollment or eligibility for a
subsidy payment under this title.

* NB Effective until January 1, 2014 or a later date to be determined
by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (v) In the event a household chooses not to provide the social
security numbers required by subparagraphs (i) and (ii) of this
paragraph, such household shall provide income documentation specified
in subparagraph (iii) of this paragraph as a condition of the child's
enrollment. Nothing in this paragraph shall be construed as obligating a
household to provide social security numbers of parents or legally
responsible adults as a condition of a child's enrollment or eligibility
for a subsidy payment under this title.

* NB Effective January 1, 2014 or a later date to be determined by the
commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (vi) Any income verification response by the department of taxation
and finance pursuant to subparagraphs (i) and (ii) of this paragraph
shall not be a public record and shall not be released by the
commissioner, the department of taxation and finance or an approved
organization except pursuant to this paragraph. Information disclosed
pursuant to this paragraph shall be limited to information necessary for
verification. Information so disclosed shall be kept confidential by the
party receiving such information. Such information shall be expunged
within a reasonable time to be determined by the commissioner and the
department of taxation and finance.

* NB Effective until January 1, 2014 or a later date to be determined
by the commisioner of health (see chapter 56 of 2013 Part D § 76 sb h)

* (vi) Any income verification response by the department of taxation
and finance pursuant to subparagraphs (i) and (ii) of this paragraph
shall not be a public record and shall not be released by the
commissioner, the department of taxation and finance, an approved
organization, or the state enrollment center, except pursuant to this
paragraph. Information disclosed pursuant to this paragraph shall be
limited to information necessary for verification. Information so
disclosed shall be kept confidential by the party receiving such
information. Such information shall be expunged within a reasonable time
to be determined by the commissioner and the department of taxation and
finance.

* NB Effective January 1, 2014 or a later date to be determined by the
commissioner of health (see chapter 56 of 2013 Pt. D § 76 sub h)

* (g) (i) Notwithstanding any inconsistent provision of law to the
contrary and subject to the availability of federal financial
participation under title XIX of the federal social security act, a
child under the age of nineteen shall be presumed to be eligible for
subsidy payments and temporarily enrolled for coverage under this title,
once during a twelve month period, beginning on the first day of the
enrollment period following the date that an approved organization
determines, on the basis of preliminary information, that a child's net
household income does not exceed the income level specified in title
eleven of article five of the social services law for children eligible
for medical assistance based on such child's age. The temporary
enrollment period shall continue until the earlier of the date an
eligibility determination is made pursuant to this title or title eleven
of article five of the social services law, or two months after the date
temporary enrollment begins; provided however, a temporary enrollment
period may be extended in the event an eligibility determination under
this title or title eleven of article five of the social services law is
not made within such two month period through no fault of the applicant
for insurance for medical assistance. The commissioner shall assure that
children who are enrolled pursuant to this paragraph receive the
appropriate follow-up for a determination of eligibility for benefits
under this title or title eleven of article five of the social services
law prior to the termination of the temporary enrollment period. The
commissioner shall assure that children and their families are informed
of all available enrollment sites in accordance with subdivision nine of
this section.

(ii) Effective September first two thousand seven, through March
thirty-first, two thousand fourteen temporary enrollment pursuant to
subparagraph (i) of this paragraph shall be provided only to children
who apply for recertification of coverage under this title who appear to
be eligible for medical assistance under title eleven of article five of
the social services law.

* NB Expires July 1, 2025

* (h) The commissioner may, in consultation with the superintendent,
promulgate rules and regulations necessary to prevent fraud and abuse in
eligibility determinations made by approved organizations pursuant to
this subdivision.

* NB Expires July 1, 2025

(i) Notwithstanding any inconsistent provision of law, rule or
regulation:

(i) A newborn child who meets the eligibility criteria set forth in
this subdivision or subdivision five of this section, as determined by
an approved organization or the health insurance exchange marketplace,
whichever is applicable, shall be enrolled retroactively to the first
day of the month in which the child is born, provided that the applicant
for insurance submits a completed and signed application and required
information and documentation within sixty days of the child's birth.

(ii) A newborn child shall be presumed eligible for subsidy payments
under this subdivision or eligible for coverage under subdivision five
of this section, provided that the applicant for insurance submits a
completed and signed application within sixty days of the child's birth.
Once eligibility is determined by the approved organization or the
health insurance exchange marketplace, whichever is applicable, on the
basis of preliminary information, the child shall be enrolled
retroactively to the first day of the month in which the child is born.
All other procedures and standards regarding presumptive enrollment
applicable to eligible children enrolled under this title and specified
in state contracts with approved organizations or implemented by the
health insurance exchange marketplace, whichever is applicable, shall
apply to presumptive enrollment of newborn children.

(j) Where an application for recertification of coverage under this
title contains insufficient information for a final determination of
eligibility for continued coverage, a child shall be presumed eligible
for a period not to exceed the earlier of two months beyond the
preceding period of eligibility or the date upon which a final
determination of eligibility is made based on the submission of
additional data. In the event such additional information is not
submitted within two months of the approved organization's or state
enrollment center's request, whichever is applicable, the approved
organization or state enrollment center shall disenroll the child
following the expiration of such two month period. Except as provided in
paragraph (c) of subdivision five-a of this section, approved
organizations shall not be obligated to repay subsidy payments received
on behalf of children enrolled during this two month period.

2-a. (a) An approved organization that has reasonable cause to believe
that an applicant for insurance, parent or legally responsible adult has
provided false income information may submit tax returns and any other
available income information, including, if not prohibited by federal
law for purposes of income verification, social security account
numbers, to the department as may be necessary to determine income
eligibility. The department shall promptly furnish to the department of
taxation and finance, pursuant to the agreements authorized by
subdivision five of section one hundred seventy-one-a and subdivision
four of section one hundred seventy-one-b of the tax law, the names,
address and social security account numbers, if available, of the
parents and legally responsible adults who are members of the household,
together with a request that the department of taxation and finance,
pursuant to those agreements, promptly ascertain insofar as is possible,
and from the most recent available data, whether the collective income
reported by those individuals exceeds the income eligibility level for
that household, as determined by the department in compliance with
paragraph (a) of subdivision two of this section. The department, in
consultation with the department of taxation and finance, shall
establish a methodology for comparing numerical equivalents. In
ascertaining whether a household's income exceeds the income eligibility
threshold transmitted by the department, the department of taxation and
finance shall also examine information available pursuant to section one
hundred seventy-one-a of the tax law where any of the named individuals
have failed to file a New York state income tax return for the most
recent filing year or where there is an indication, from the department
or otherwise, that the individual's income may have changed. Reliance on
such section one hundred seventy-one-a information shall be specially
indicated in the department of taxation and finance's response. This
provision shall not be construed to authorize the department of taxation
and finance to disclose any figure on any personal income tax return.
The department shall promptly inform the approved organization of the
response from the department of taxation and finance. Submission of
income information for verification shall not delay the application of
any other provision of this section to an applicant for insurance or an
enrolled child.

(b) Before an approved organization submits income information to the
department for verification with the department of taxation and finance,
it shall:

(i) provide the applicant for insurance with notification of its
intent to seek such verification;

(ii) notify the applicant for insurance of the confidentiality and
expungement provisions contained in paragraph (c) of this subdivision;
and

(iii) provide the applicant for insurance with the opportunity to
review and modify the income information.

(c) Such income information and verification response by the
department of taxation and finance shall not be a public record and
shall not be released by the department, the department of taxation and
finance or the approved organization except pursuant to this
subdivision. Information disclosed pursuant to this section shall be
limited to information necessary for verification. Information so
disclosed shall be kept confidential by the party receiving such
information. Such income information shall be expunged within a
reasonable time to be determined by the department and the department of
taxation and finance.

2-b. (a) For purposes of claiming federal financial participation
under paragraph nine of subsection (c) of section twenty-one hundred
five of the federal social security act, a household shall provide:

(i) the social security number for the applicant to be verified by the
commissioner in accordance with a process established by the social
security administration pursuant to federal law, or

(ii) documentation of citizenship and identity of the applicant
consistent with requirements under the medical assistance program, as
specified by the commissioner on the initial application.

(b) Pending receipt of the information required by subparagraph (i) of
paragraph (a) of this subdivision, an initial application shall continue
to be processed by an approved organization or enrollment facilitator
and a child shall be presumptively enrolled in the program in accordance
with procedures and timeframes currently specified in contracts.

2-c. Express lane eligibility. (a) Notwithstanding any inconsistent
provision of law, rule or regulation, the commissioner is authorized to
(i) establish standards and procedures for express lane enrollment and
renewal implemented in accordance with section 2107(e)(1)(B) of the
federal social security act, including but not limited to reliance on a
finding made by an express lane agency, as defined in section
1902(e)(13)(F) of the federal social security act, to determine whether
a child meets one or more of the eligibility criteria set forth in
subdivision two of this section; (ii) specify such standards and
procedures in the state child health plan established under title XXI of
the federal social security act and applicable contracts with approved
organizations and enrollment facilitators; and (iii) waive any
information and documentation requirements set forth in this section
necessary to implement express lane eligibility pursuant to standards
and procedures established under subparagraphs (i) and (ii) of this
paragraph; provided, however, that information and documentation
required pursuant to subdivision two-b of this section may not be
waived.

(b) Subject to federal approval, such standards and procedures shall
specify that information and documentation regarding citizenship and
immigration status collected by an express lane agency and provided to
the commissioner for the purpose of express lane eligibility may be used
to satisfy the requirements of subdivision two-b of this section.

(c) Such standards and procedures shall also include a process for
determining enrollment error rates and implementing corrective actions
as required by section 1902(e)(13)(E) of the federal social security
act.

3. Subsidy payments shall be made, pursuant to subdivision eight of
this section, to approved organizations for the purposes of subsidizing
the entire cost of coverage for eligible children meeting the criteria
of subdivision two of this section. Notwithstanding any inconsistent
provision of this subdivision, the total annual aggregate cost-sharing
with respect to all eligible children in a family under this section
shall not exceed amounts provided pursuant to applicable federal law. In
order to be eligible for a subsidy payment pursuant to this subdivision
a premium payment shall be paid for an eligible child in accordance with
the provisions of subdivision nine of section twenty-five hundred ten of
this title. Nothing herein shall preclude payment of the premium on
behalf of an eligible child on a monthly, quarterly, semi-annual or
annual basis.

4. Households shall report to the approved organization or state
enrollment center, whichever is applicable, within thirty days, any
changes in New York state residency or health care coverage under
insurance that may make a child ineligible for subsidy payments pursuant
to this section. Any individual who, with the intent to obtain benefits,
willfully misstates income or residence to establish eligibility
pursuant to subdivision two of this section or willfully fails to notify
an approved organization or state enrollment center of a change in
residence or health care coverage pursuant to this subdivision shall
repay such subsidy to the commissioner. Individuals seeking to enroll
children for coverage shall be informed that such willful misstatement
or failure to notify shall result in such liability.

4-a. Any individual who, with the intent to obtain benefits, willfully
misstates income or residence to establish eligibility pursuant to
subdivision two of this section or willfully fails to notify an approved
organization of an increase in income or change in residence pursuant to
subdivision two of this section shall repay such subsidy to the
commissioner. Individuals seeking to enroll children for coverage shall
be informed that such willful misstatement or failure to notify shall
result in such liability.

5. Notwithstanding any inconsistent provisions of subdivision two of
this section, an individual who meets the criteria of paragraphs (b) and
(c) of subdivision two of this section but not the criteria of paragraph
(a) of such subdivision may be enrolled for covered health care
services, provided however, that an approved organization shall not be
eligible to receive a subsidy payment for providing coverage to such
individuals. The cost of coverage shall be determined by the
commissioner, in consultation with the superintendent and shall be no
more than the cost of providing such coverage.

5-a. Obligations of approved organizations or the state enrollment
center. (a) An approved organization or state enrollment center,
whichever is applicable, shall have the obligation to review all
information provided pursuant to subdivision two of this section and
shall not certify or recertify a child as eligible for a subsidy payment
unless the child meets the eligibility criteria.

(b) An approved organization or state enrollment center, whichever is
applicable, shall promptly review all information relating to a
potential change in eligibility based on information provided pursuant
to subdivision four of this section. Within at least thirty days after
receipt of such information, the approved organization or state
enrollment center shall make a determination whether the child is still
eligible for a subsidy payment and shall notify the household and the
commissioner if it determines the child is not eligible for a subsidy
payment.

(c) Any approved organization which engages in a pattern and practice
of enrolling or recertifying children who are ineligible pursuant to
subdivision two of this section, as determined by the commissioner, in
consultation with the superintendent, shall be required to repay all
subsidy payments received on account of ineligible children. Improper
enrollment based upon a good faith reliance on documentation which
appears accurate on its face shall not constitute a pattern or practice.
Any such approved organization may also be removed as an approved
organization, provided however, that eligible children shall continue to
receive services until such time as the orderly transition to other
approved organizations can be effected.

6. The commissioner shall, in consultation with the superintendent,
establish guidelines for the submission of proposals by eligible
organizations for the purposes of providing covered health care services
coverage to eligible children including, but not limited to, the
following components:

(a) standards for individual enrollment including mechanisms for
presumptive eligibility and annual recertification;

(b) standards for provider enrollment;

(c) standards for scope of covered health care service benefits;

(d) standards for health care provider payment methodologies, provided
however, that levels and methods of payment shall be consistent with
those provided under similar insurance plans;

(e) standards for appropriate utilization review, quality assurance
and case management mechanisms; and

(f) such other criteria which may be deemed necessary.

6-a. The commissioner, in consultation with the superintendent, may
establish a program for cards issued to eligible children which can
store or access information electronically, including the identity of
the child and such other medical data and information as the
commissioner, in consultation with the superintendent, may prescribe.

7. (a) A proposal submitted by an eligible organization shall meet the
following criteria:

(i) designate the geographic area to be served by the program, and
estimate the number of eligible participants and actual participants in
such designated area;

(ii) assure access to and delivery of high quality, appropriate
covered health care services and, when applicable, include a network of
health care providers in sufficient numbers and geographically
accessible to service program participants;

(iii) describe the procedures for marketing and determining
eligibility for the health care coverage plan in the program location,
including the designation of other entities which may perform such
functions under contract with the organization;

(iv) describe proposed health care provider payment methodologies;

(v) describe in detail the estimated expenses, including personnel
costs and other types of administrative expenses which will be incurred
in the development and implementation of the program;

(vi) describe the quality assurance, utilization review and case
management mechanisms to be implemented;

(vii) demonstrate the applicant's ability to meet the data analysis
and reporting requirements of the program;

(viii) describe the benefit package to be offered by the program and
the cost of such benefit package;

(ix) describe the provisions for arranging for or offering conversion
coverage in the event of termination of coverage under this title;

(x) demonstrate financial feasibility of the program;

(xi) describe the premium, copayments and deductibles to be paid by
program participants who are ineligible for subsidy payments; and

(xii) include such other information as the commissioner and the
superintendent may deem appropriate.

(b) The commissioner, in consultation with the superintendent, shall
make a determination whether to approve, disapprove or recommend
modification of the proposal. In order for a proposal to be approved by
the commissioner, the proposal must also be approved by the
superintendent with respect to the provisions of subparagraphs (ix) and
(xii) of paragraph (a) of this subdivision.

(c) The commissioner, in consultation with the superintendent, shall
ensure, to the extent possible, that child health insurance plan
coverage is available in all geographic areas. The commissioner may
approve more than one approved organization to serve all or part of a
geographic area.

7-a. (a) Notwithstanding any inconsistent provisions of subdivisions
one and three of section two thousand five hundred ten of this title,
subdivisions six and seven of this section, subject to paragraph (b) of
this subdivision, and section one hundred sixty-three of the state
finance law, the commissioner may contract with organizations approved
under section three hundred sixty-four-j of the social services law,
without a competitive bid or request for proposal process, to provide
covered health care services coverage for eligible children pursuant to
this title.

(b) In order to be approved pursuant to this subdivision, an
organization shall meet the criteria set forth in subdivision seven of
this section and shall comply with standards established by the
commissioner, in consultation with the superintendent, pursuant to
subdivision six of this section.

(c) Organizations approved pursuant to this subdivision shall comply
with the requirements of this title and contractual provisions
established thereunder, title XXI of the federal social security act and
any implementing federal regulations, and requirements set forth in the
state child health plan established pursuant to title XXI of the federal
social security act.

(d) Notwithstanding any inconsistent provision of section one hundred
twelve or one hundred sixty-three of the state finance law, at the
discretion of the commissioner, without a competitive bid or request for
proposal process, contractual arrangements with approved organizations,
as defined in subdivision two of section twenty-five hundred ten of this
article, in effect in two thousand seven may be extended to any period
on and after July first, two thousand seven to provide an uninterrupted
continuation of services and may be amended as deemed necessary.

8. The commissioner shall determine the amount of funds to be
allocated to an approved organization for the purposes described in
subdivision one of this section within such funds which may be available
for the purposes of this article. (a) Subsidy payments made to approved
organizations on and after April first, two thousand five through March
thirty-first, two thousand six, shall be at amounts approved prior to
April first, two thousand five. Applications for increases to subsidy
payments submitted by approved organizations to the superintendent on or
after January first, two thousand five, shall not be considered for
approval until after March thirty-first, two thousand six. (b) Further,
subsidy payments made to approved organizations on and after April
first, two thousand seven through March thirty-first, two thousand
eight, shall be at amounts approved prior to April first, two thousand
seven. Applications for increases to subsidy payments submitted by
approved organizations to the superintendent on or after January first,
two thousand seven, shall not be considered for approval until after
March thirty-first, two thousand eight. (c) Nothing in this subdivision
shall prohibit decreases in subsidy payments in accordance with relevant
contract provisions.

(d)(i) Effective April first, two thousand nine, payment for marketing
and facilitated enrollment activities set forth in subdivision nine of
this section and included in subsidy payments made to approved
organizations providing such services pursuant to a contract with the
state shall be limited to an amount determined annually by the
commissioner.

(ii) Such subsidy payments shall be adjusted by the commissioner to
remove any costs of approved organizations in excess of the amount
determined in accordance with subparagraph (i) of this paragraph based
on cost reports submitted to the department by approved organizations.

(f) The commissioner shall adjust subsidy payments made to approved
organizations on and after April first, two thousand eleven through
March thirty-first, two thousand twelve, so that the amount of each such
payment is reduced by one and seven-tenths percent.

(g) The commissioner may increase subsidy payments made to approved
organizations that voluntarily participate in the multi-payor patient
centered medical home program to reflect additional costs associated
with enhanced payments made to certified medical homes by approved
organizations as required by article twenty-nine-AA of this chapter.

(h) Notwithstanding any inconsistent provision of this title, articles
thirty-two and forty-three of the insurance law and subsection (e) of
section eleven hundred twenty of the insurance law, for the period April
first, two thousand fourteen through March thirty-first, two thousand
fifteen, subsidy payments made to approved organizations shall be at
amounts approved prior to April first, two thousand fourteen.

(i) Notwithstanding any inconsistent provision of this title, articles
thirty-two and forty-three of the insurance law and subsection (e) of
section eleven hundred twenty of the insurance law:

(i) The commissioner shall, subject to approval of the director of the
division of the budget, develop reimbursement methodologies for
determining the amount of subsidy payments made to approved
organizations for the cost of covered health care services coverage
provided pursuant to this title for payments made on and after January
first, two thousand twenty-four.

(ii) Effective January first, two thousand twenty-three, the
commissioner shall coordinate with the superintendent of financial
services for the transition of the subsidy payment rate setting function
to the department and, in conjunction with its independent actuary,
review reimbursement methodologies developed in accordance with
subparagraph (i) of this paragraph. Notwithstanding section one hundred
sixty-three of the state finance law, the commissioner may select and
contract with the independent actuary selected pursuant to subdivision
eighteen of section three hundred sixty-four-j of the social services
law, without a competitive bid or request for proposal process. 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 subsidy payment amounts in relation to the population to be served
adjusted for case mix, the scope of services approved organizations must
provide, the utilization of such services and the network of providers
required to meet state standards.

9. The commissioner shall, within amounts available therefor, contract
with community-based and other marketing organizations for purposes of
public education, outreach, and recruitment of eligible children,
including the distribution of applications and information regarding
enrollment. In awarding such contracts, the commissioner shall consider
the marketing, outreach and recruitment efforts of approved
organizations, and the extent to which such organizations are able to
effectively target efforts in geographic regions where the proportion of
eligible children enrolled under this title are lower than in other
geographic regions of the state. Community-based organizations shall
include, but not be limited to: day care centers, schools,
community-based diagnostic and treatment centers, and hospitals.

10. Notwithstanding any other law or agreement to the contrary, and
except in the case of a child or children who also becomes eligible for
medical assistance, benefits under this title shall be considered
secondary to any other plan of insurance or benefit program, except the
children and youth with special health care needs support services
program and the early intervention program, under which an eligible
child may have coverage.

11. (a) An approved organization shall submit required reports and
information to the commissioner in such form and at times, at least
annually, as may be required by the commissioner and specified in
contracts and official department of health administrative guidance, in
order to evaluate the operations and results of the program and quality
of care being provided by such organizations. Such reports and
information shall include, but not be limited to, enrollee demographics
(applicable only until the state enrollment center is implemented),
program utilization and expense, patient care outcomes and patient
specific medical information, including encounter data maintained by an
approved organization for purposes of quality assurance and oversight.
Any information or data collected pursuant to this paragraph shall be
kept confidential in accordance with Title XXI of the federal social
security act or any other applicable state or federal law.

(b) In the event an approved organization fails to submit any required
report and information, as specified in contracts and official
department of health administrative guidance, on or before the due date
specified by the commissioner, the commissioner may reduce the approved
organization's subsidy payments by up to a total of two percent each
month for a period beginning on the first day of the calendar month
following the original due date of the required report and information
and continuing until the last day of the calendar month in which the
required report and information are submitted; provided however, an
approved organization shall not be subject to the percentage reduction
under the following conditions: (i) for any new report for which such
organization did not have reasonable notice which shall be at least
sixty days notice of its requirement, data and submission
specifications, and due date by certified mail to the approved
organization's chief financial officer; or (ii) for any report, upon a
finding by the commissioner that such report was not submitted on a
timely basis for good cause, which may include, but not be limited to,
additional time required to modify or add to computer data systems.

12. The commissioner shall, in consultation with the superintendent,
establish procedures to coordinate the child health insurance plan with
the medical assistance program, including but not limited to, procedures
to maximize enrollment of eligible children under those programs by
identification and transfer of children who are eligible or who become
eligible to receive medical assistance and procedures to facilitate
changes in enrollment status for children who are ineligible for
subsidies under this section and for children who are no longer eligible
for medical assistance in order to facilitate and ensure continuity of
coverage. The commissioner shall review, on an annual basis, the
eligibility verification and recertification procedures of approved
organizations under this title to insure the appropriate enrollment of
children. Such review shall include, but not be limited to, an audit of
a statistically representative sample of cases from among all approved
organizations and shall be applicable to any period during which an
approved organization's responsibilities include determining
eligibility. In the event such review and audit reveals cases which do
not meet the eligibility criteria for coverage set forth in this
section, that information shall be forwarded to the approved
organization and the commissioner for appropriate action.

12-a. The commissioner shall establish procedures to audit approved
organizations for compliance with the requirements of this title,
including the requirements of subdivision twelve of this section,
contractual provisions established thereunder and advisory memoranda
issued by the commissioner, title XXI of the federal social security act
and any implementing federal regulations, and requirements set forth in
the state child health plan established pursuant to title XXI of the
federal social security act. Approved organizations shall comply with
such procedures and make available any data necessary to perform such
audits. Audit procedures shall include, but not be limited to, the
following:

(a) standards and procedures for a preliminary audit to be conducted
on no more than an annual basis;

(b) standards and procedures for the submission of a plan of
correction by an approved organization, including time periods allowed
to implement such plan of correction;

(c) standards and procedures for a second audit, including an exit
conference which provides an approved organization the opportunity to
rebut the composition of the audit sample as representative prior to
recovery of subsidy payments and the imposition of penalties;

(d) standards and procedures for recovery of subsidy payments made for
ineligible children, which, notwithstanding any inconsistent provisions
of this title, may include recoveries based on extrapolated findings
from a statistically representative sample of cases which shall be
actuarially based and consistent with accepted auditing standards; and

(e) standards and procedures for the imposition of penalties for
substantial noncompliance, which may include, but not be limited to,
financial penalties in addition to penalties set forth in section twelve
of this chapter and consistent with applicable federal standards, as
specified in contracts, and contract termination; provided however

(f) audit standards and procedures established pursuant to this
section, including penalties, shall be applicable to eligibility
determinations made by approved organizations only for periods during
which an approved organization's responsibilities include making such
eligibility determinations.

14. The commissioner, in consultation with the superintendent, shall
enter into agreements with one or more persons, not-for-profit
corporations, or other organizations, other than a state employee,
official or agency, for the performance of a comprehensive evaluation of
the implementation and effectiveness of the child health insurance
program. Notwithstanding any inconsistent provision of law, the
commissioner may allocate and distribute from funds otherwise available
for distribution for purposes of this title an amount not to exceed five
hundred thousand dollars for the costs of such evaluation. The
evaluation shall include, but not be limited to:

(a) the overall effect of the child health insurance program on access
to, utilization and quality of primary and preventive health care
services, including, but not limited to, patterns of service
utilization, geographic availability of service providers, possible
reductions in uncompensated care as a result of the program, and
enrollee satisfaction with program administration, services and quality;

(b) the impact of the child health insurance program on the health
status of program participants, including the comparative impact on
families that have a child enrolled in the program and other children
that are not eligible and do not have coverage;

(c) the effect of the child health insurance program on emergency room
utilization, including the effectiveness of preventing inappropriate
utilization;

(d) the geographic accessibility of the child health insurance
program, including the availability and accessibility of service
providers, premium levels and premium increases;

(e) the effect of community-based and statewide outreach education
efforts;

(f) the results of a statistically valid sampling of cases verifying
certification and recertification of eligibility for subsidy payments
under this title including but not limited to data on failure by
approved organizations to adequately verify enrollee eligibility;

(g) any recommendations for programmatic changes to improve the child
health insurance program based on program evaluation and enrollee
satisfaction data; and

(h) a cost and patient outcome comparison of indemnity plans and
managed care plans offered under this program.

A preliminary evaluation shall be submitted to the governor and the
legislature by April first, nineteen hundred ninety-five and a further
evaluation shall be submitted by January first, nineteen hundred
ninety-six.

14-a. The commissioner shall enter into an agreement with one or more
persons, not-for-profit corporations, or other organizations, other than
a state employee, official or agency, for comprehensive research
concerning the health care coverage of children in New York state. The
organization conducting the research shall, at least annually, issue a
report of its findings to the governor and the legislature. The research
shall include, but not be limited to:

(a) a survey of the uninsured in the state;

(b) on-going comprehensive studies of the characteristics of uninsured
children and their families, including demographic characteristics, and
reasons such children and families are uninsured;

(c) the collection and dissemination of data and other relevant
information relating to the health care coverage of children and their
families; and

(d) a review of such factors relating to the uninsured in New York
state as the commissioner, in consultation with the superintendent,
shall require.

15. Notwithstanding any inconsistent provision of section one hundred
twelve or one hundred sixty-three of the state finance law or any other
law, at the discretion of the commissioner without a competitive bid or
request for proposal process:

(a) contractual arrangements with approved organizations to provide
primary and preventive health care services coverage for eligible
children, or with organizations for purposes of public education,
outreach and recruitment of eligible children, in effect in nineteen
hundred ninety-three may be extended to provide for primary and
preventive health care services coverage for eligible children or public
education, outreach and recruitment of eligible children in nineteen
hundred ninety-four and nineteen hundred ninety-five and those
contractual arrangements with approved organizations to provide primary
and preventive health care services coverage for eligible children in
effect for nineteen hundred ninety-five may be extended through June
thirtieth, nineteen hundred ninety-six to provide an uninterrupted
continuation of services and additional time for program evaluation and
may be amended as may be necessary, provided, however, that the
commissioner shall periodically review the process of ensuring adequate
participation of approved organizations under this section; and

(b) contractual arrangements with approved organizations to provide
primary and preventive health care services coverage for eligible
children, or with organizations for purposes of public education,
outreach and recruitment of eligible children in effect in the period
January first, nineteen hundred ninety-six through June thirtieth,
nineteen hundred ninety-six may be extended for public education,
outreach and recruitment of eligible children through December
thirty-first, nineteen hundred ninety-six and to provide for primary and
preventive health care services coverage for eligible children through
such periods for which such coverage continues to apply prior to the
addition of coverage for inpatient health care services to provide an
uninterrupted continuation of services and may be amended as may be
necessary.

* 16. The commissioner and the commissioner of social services shall
jointly develop a simplified application form for coverage under this
title, the medical assistance program and the federal women, infants and
children program, and shall also develop appropriate verification and
sampling procedures for the child health insurance plan in order to
facilitate the appropriate enrollment of eligible children into the
child health insurance plan, the medical assistance program, and the
women, infants and children program. Nothing in this subdivision shall
be construed to require that eligibility documentation requirements for
the services under this title shall apply to the medical assistance
program, nor shall this subdivision be construed to preclude eligibility
for any person pending the development of that application. Such
application shall be available for use by local social services
districts and approved organizations under this title by June thirtieth,
nineteen hundred ninety-four.

* NB Expired July 1, 2007

16-a. The commissioner shall develop a simplified recertification form
for use by approved organizations in renewing coverage for eligible
children under this title. The form shall include requests only for such
information that is: (i) reasonably necessary to determine continued
eligibility for coverage under this title; and (ii) subject to change
since the date of the household's initial application.

17. The commissioner, in consultation with the superintendent, is
authorized to establish and operate a child health information service
which shall utilize advanced telecommunications technologies to meet the
health information and support needs of children, parents and medical
professionals, which shall include, but not be limited to, treatment
guidelines for children, treatment protocols, research articles and
standards for the care of children from birth through eighteen years of
age. Such information shall not constitute the practice of medicine, as
defined in article one hundred thirty-one of the education law.

18. Premium Assistance Program. (a) The commissioner shall establish a
premium assistance program for the purchase of family coverage under a
group health plan or health insurance coverage that includes coverage of
an eligible child, as defined in subdivision four of section twenty-five
hundred ten of this article, contingent upon:

(i) a determination by the commissioner that the purchase of family
coverage under this subdivision is cost effective relative to the amount
the state would pay to obtain coverage under this title solely for the
eligible child or children; and

(ii) the availability of federal financial participation in accordance
with a waiver application submitted by the commissioner and approved by
the secretary of the department of health and human services.

(b) The commissioner shall establish and specify standards for the
implementation of the premium assistance program in the federal waiver
application, including, but not limited to, the following:

(i) standards for eligibility of children and families for and
enrollment in the premium assistance program which shall include, at a
minimum, the eligibility criteria set forth in subdivision two of this
section; provided that:

(A) participation in the program for a child who resides in a
household having a household income at or below two hundred fifty
percent of the non-farm federal poverty level (as defined and updated by
the United States department of health and human services) shall be
voluntary and an eligible child may disenroll from the premium
assistance program at any time and enroll in individual coverage under
this title; and

(B) participation in the program for a child who resides in a
household having a household income between two hundred fifty-one and
four hundred percent of the non-farm federal poverty level (as defined
and updated by the United States department of health and human
services) and meets certain eligibility criteria shall be mandatory. A
child in this income group who meets the criteria for enrollment in the
premium assistance program shall not be eligible for individual coverage
under this title;

(ii) standards for required levels of employer contributions toward
the cost of premiums for family coverage;

(iii) standards for the level of state payment toward the cost of
premiums for family coverage;

(iv) standards for the scope and level of benefits to be provided in
the premium assistance program;

(v) standards for data collection including, but not limited to, data
regarding the substitution of health insurance coverage that would be
provided to eligible children in the absence of family coverage
purchased pursuant to this subdivision; and

(vi) any other standards deemed necessary by the commissioner to
implement the premium assistance program.

(c) The state share of the cost of the premium assistance program, if
implemented, shall be funded within amounts appropriated for the purpose
of providing healthcare coverage for uninsured and underinsured children
pursuant to this title.

19. Claims submitted to an approved organization for payment for
medical care, services, or supplies furnished by an out-of-network
health care provider must be submitted within fifteen months of the date
the medical care, services, or supplies were furnished to an eligible
person to be valid and enforceable against the approved organization. If
a claim by an out-of-network health care provider is not submitted
within fifteen months of the date that the medical care, services or
supplies were furnished and the claim is subsequently denied by the
approved organization for that reason, such out-of-network health care
provider shall not seek payment for such medical care, services or
supplies from the enrollee. This deadline for claims submission shall
not apply where the claims submission is warranted to address findings
or recommendations identified in a state or federal audit except where
such audit also indicates that an inappropriate provider payment was
solely the fault of the out-of-network health care provider.

20. For approved organizations with negotiated rates of payment for
inpatient hospital services under contracts in effect on April first,
two thousand eight, that have a payment rate methodology for such
inpatient hospital services that utilizes rates calculated by the
department of health pursuant to paragraph (a) or (a-2) of subdivision
one of section twenty-eight hundred seven-c of the public health law for
patients under the medical assistance program, such rate shall not
include adjustments pursuant to subdivision thirty-three of section
twenty-eight hundred seven-c of this chapter for contract periods prior
to January first, two thousand ten.

21. The commissioner may make any necessary amendments to a contract
pursuant to this section with an approved organization, as defined in
subdivision two of section twenty-five hundred ten of this title, to
allow such approved organization to participate as a qualified health
plan in a state health benefit exchange established pursuant to the
federal Patient Protection and Affordable Care Act (P.L. 111-148), as
amended by the federal Health Care and Education Reconciliation Act of
2010 (P.L. 111-152).

22. Notwithstanding the provisions of this title and effective on and
after January first, two thousand twenty-three, the consultative,
review, and approval functions of the superintendent of financial
services related to administration of the child health insurance plan
are no longer applicable and references to those functions in this title
shall be null and void. The child health insurance plan set forth in
this title shall be administered solely by the commissioner. All child
health insurance plan policies reviewed and approved by the
superintendent of financial services in accordance with section eleven
hundred twenty of the insurance law shall remain in effect until the
commissioner establishes a process to review and approve member
handbooks in accordance with the requirements of Title XXI of the
federal social security act and implementing regulations, and such
member handbooks are issued by approved organizations to enrollees in
place of child health insurance plan policies which were subject to
review under section eleven hundred twenty of the insurance law.