Legislation
SECTION 268-C
Functions of the Marketplace
Public Health (PBH) CHAPTER 45, ARTICLE 2, TITLE 7
§ 268-c. Functions of the Marketplace. The Marketplace shall:
1. (a) Perform eligibility determinations for federal and state
insurance affordability programs including medical assistance in
accordance with section three hundred sixty-six of the social services
law, child health plus in accordance with section twenty-five hundred
eleven of this chapter, the basic health program in accordance with
section three hundred sixty-nine-gg of the social services law, the 1332
state innovation program in accordance with section three hundred
sixty-nine-ii of the social services law, premium tax credits and
cost-sharing reductions and qualified health plans in accordance with
applicable law and other health insurance programs as determined by the
commissioner;
(b) certify and make available to qualified individuals, qualified
health plans, including dental plans, certified by the Marketplace
pursuant to applicable law, provided that coverage under such plans
shall not become effective prior to certification by the Marketplace;
and
(c) certify and/or make available to eligible individuals, health
plans certified by the Marketplace pursuant to applicable law, and/or
participating in an insurance affordability program pursuant to
applicable law, provided that coverage under such plans shall not become
effective prior to certification by the Marketplace, and/or approval by
the commissioner.
2. Assign an actuarial value to each Marketplace certified plan
offered through the Marketplace in accordance with the criteria
developed by the secretary pursuant to federal law or the superintendent
pursuant to the insurance law and/or requirements developed by the
Marketplace, and determine each health plan's level of coverage in
accordance with regulations issued by the secretary pursuant to federal
law or the superintendent pursuant to the insurance law.
3. Utilize a standardized format for presenting health benefit options
in the Marketplace, including the use of the uniform outline of coverage
established under section 2715 of the federal public health service act
or the insurance law.
4. Standardize the benefits available through the Marketplace at each
level of coverage defined by the superintendent in the insurance law.
5. Maintain enrollment periods in the best interest of qualified
individuals consistent with federal and state law.
6. Implement procedures for the certification, recertification and
decertification of health plans as qualified health plans or health
plans approved for sale by the department of financial services or
department of health and certified by the Marketplace, consistent with
guidelines developed by the secretary pursuant to section 1311(c) of the
federal act and requirements developed by the Marketplace.
7. Contract for health care coverage offered to qualified individuals
through the Marketplace, and in doing so shall seek to provide health
care coverage choices that offer the optimal combination of choice,
value, quality, and service.
8. Contract for health care coverage offered to certain eligible
individuals through the Marketplace, pursuant to health insurance
programs as determined by the commissioner, and in doing so shall seek
to provide health care coverage choices that offer the optimal
combination of choice, value, quality, and service;
9. Provide the minimum requirements an insurer shall meet to
participate in the Marketplace, in the best interest of qualified
individuals or eligible individuals;
10. Require qualified health plans and/or other health plans certified
by the Marketplace to offer those benefits determined to be essential
health benefits pursuant to state law or as required by the Marketplace.
11. Ensure that insurers offering health plans through the Marketplace
do not charge an individual enrollee a fee or penalty for termination of
coverage.
12. Provide for the operation of a toll-free telephone hotline to
respond to requests for assistance.
13. Maintain an internet website through which enrollees and
prospective enrollees of qualified health plans and health plans
certified by the Marketplace may obtain standardized comparative
information on such plans and insurance affordability programs.
14. Make available by electronic means a calculator to determine the
actual cost of coverage after the application of any premium tax credit
under section 36B of the Internal Revenue Code of 1986 or applicable
state law and any cost-sharing reduction under federal or applicable
state law.
15. Operate a program under which the Marketplace awards grants to
entities to serve as navigators in accordance with applicable federal
law and regulations adopted thereunder, and/or a program under which the
Marketplace awards grants to entities to provide community based
enrollment assistance in accordance with requirements developed by the
Marketplace; and/or a program under which the Marketplace certifies New
York state licensed producers to provide assistance to eligible
individuals and/or small employers pursuant to federal or state law.
16. In accordance with applicable federal and state law, inform
individuals of eligibility requirements for the Medicaid program under
title XIX of the social security act and the social services law, the
children's health insurance program (CHIP) under title XXI of the social
security act and this chapter, the basic health program under section
three hundred sixty-nine-gg of the social services law, the 1332 state
innovation program in accordance with section three hundred
sixty-nine-ii of the social services law, or any applicable state or
local public health insurance program and if, through screening of the
application by the Marketplace, the Marketplace determines that such
individuals are eligible for any such program, enroll such individuals
in such program.
17. Grant a certification that an individual is exempt from the
requirement to maintain minimum essential coverage pursuant to federal
or state law and from any penalties imposed by such requirements
because:
(a) there is no affordable health plan available covering the
individual, as defined by applicable law; or
(b) the individual meets the requirements for any other such exemption
from the requirement to maintain minimum essential coverage or to pay
the penalty pursuant to applicable federal or state law.
18. Operate a small business health options program ("SHOP") pursuant
to section 1311 of the federal act and applicable state law, through
which eligible small employers may select marketplace-certified
qualified health plans offered in the small group market, and through
which eligible small employers may receive assistance in qualifying for
small business tax credits available pursuant to federal and state law.
19. Enter into agreements as necessary with federal and state agencies
and other state Marketplaces to carry out its responsibilities under
this title, provided such agreements include adequate protections with
respect to the confidentiality of any information to be shared and
comply with all state and federal laws and regulations.
20. Perform duties required by the secretary, the secretary of the
United States department of the treasury or the commissioner related to
determining eligibility for premium tax credits or reduced cost-sharing
under applicable federal or state law.
21. Meet program integrity requirements under applicable law,
including keeping an accurate accounting of receipts and expenditures
and providing reports to the secretary regarding Marketplace related
activities in accordance with applicable law.
22. Submit information provided by Marketplace applicants for
verification as required by section 1411(c) of the federal act and
applicable state law.
23. Establish rules and regulations that do not conflict with or
prevent the application of regulations promulgated by the secretary.
24. Determine eligibility, provide notices, and provide opportunities
for appeal and redetermination in accordance with the requirements of
federal and state law.
25. The commissioner is authorized to submit the appropriate waiver
applications to the United States secretary of health and human services
and/or the department of the treasury to waive any applicable provisions
of the Patient Protection and Affordable Care Act, Pub. L. 111-148 as
amended, or successor provisions, as provided for by 42 U.S.C. 18052,
and any other waivers necessary to achieve the purposes of high quality,
affordable coverage through NY State of Health, the official health plan
marketplace. The commissioner shall implement the state plans of any
such waiver in a manner consistent with applicable state and federal
laws, as authorized by the secretary of health and human services and/or
the secretary of the treasury pursuant to 42 U.S.C. 18052. Copies of
such original waiver applications and amendments thereto shall be
provided to the chair of the senate finance committee, the chair of the
assembly ways and means committee and the chairs of the senate and
assembly health committees simultaneously with their submission to the
federal government.
* 26. Subject to federal approval if required, the use of state funds
and the availability of funds in the 1332 state innovation program fund
established pursuant to section ninety-eight-d of the state finance law,
the commissioner shall have the authority to establish a program to
provide subsidies for the payment of premium or cost sharing or both to
assist individuals who are eligible to purchase qualified health plans
through the marketplace, or take such other action as appropriate to
reduce or eliminate qualified health plan premiums or cost-sharing or
both.
* NB Effective upon the commissioner of health obtaining and
maintaining certain approvals (see chapter 57 of 2024 Pt. J § 10)
1. (a) Perform eligibility determinations for federal and state
insurance affordability programs including medical assistance in
accordance with section three hundred sixty-six of the social services
law, child health plus in accordance with section twenty-five hundred
eleven of this chapter, the basic health program in accordance with
section three hundred sixty-nine-gg of the social services law, the 1332
state innovation program in accordance with section three hundred
sixty-nine-ii of the social services law, premium tax credits and
cost-sharing reductions and qualified health plans in accordance with
applicable law and other health insurance programs as determined by the
commissioner;
(b) certify and make available to qualified individuals, qualified
health plans, including dental plans, certified by the Marketplace
pursuant to applicable law, provided that coverage under such plans
shall not become effective prior to certification by the Marketplace;
and
(c) certify and/or make available to eligible individuals, health
plans certified by the Marketplace pursuant to applicable law, and/or
participating in an insurance affordability program pursuant to
applicable law, provided that coverage under such plans shall not become
effective prior to certification by the Marketplace, and/or approval by
the commissioner.
2. Assign an actuarial value to each Marketplace certified plan
offered through the Marketplace in accordance with the criteria
developed by the secretary pursuant to federal law or the superintendent
pursuant to the insurance law and/or requirements developed by the
Marketplace, and determine each health plan's level of coverage in
accordance with regulations issued by the secretary pursuant to federal
law or the superintendent pursuant to the insurance law.
3. Utilize a standardized format for presenting health benefit options
in the Marketplace, including the use of the uniform outline of coverage
established under section 2715 of the federal public health service act
or the insurance law.
4. Standardize the benefits available through the Marketplace at each
level of coverage defined by the superintendent in the insurance law.
5. Maintain enrollment periods in the best interest of qualified
individuals consistent with federal and state law.
6. Implement procedures for the certification, recertification and
decertification of health plans as qualified health plans or health
plans approved for sale by the department of financial services or
department of health and certified by the Marketplace, consistent with
guidelines developed by the secretary pursuant to section 1311(c) of the
federal act and requirements developed by the Marketplace.
7. Contract for health care coverage offered to qualified individuals
through the Marketplace, and in doing so shall seek to provide health
care coverage choices that offer the optimal combination of choice,
value, quality, and service.
8. Contract for health care coverage offered to certain eligible
individuals through the Marketplace, pursuant to health insurance
programs as determined by the commissioner, and in doing so shall seek
to provide health care coverage choices that offer the optimal
combination of choice, value, quality, and service;
9. Provide the minimum requirements an insurer shall meet to
participate in the Marketplace, in the best interest of qualified
individuals or eligible individuals;
10. Require qualified health plans and/or other health plans certified
by the Marketplace to offer those benefits determined to be essential
health benefits pursuant to state law or as required by the Marketplace.
11. Ensure that insurers offering health plans through the Marketplace
do not charge an individual enrollee a fee or penalty for termination of
coverage.
12. Provide for the operation of a toll-free telephone hotline to
respond to requests for assistance.
13. Maintain an internet website through which enrollees and
prospective enrollees of qualified health plans and health plans
certified by the Marketplace may obtain standardized comparative
information on such plans and insurance affordability programs.
14. Make available by electronic means a calculator to determine the
actual cost of coverage after the application of any premium tax credit
under section 36B of the Internal Revenue Code of 1986 or applicable
state law and any cost-sharing reduction under federal or applicable
state law.
15. Operate a program under which the Marketplace awards grants to
entities to serve as navigators in accordance with applicable federal
law and regulations adopted thereunder, and/or a program under which the
Marketplace awards grants to entities to provide community based
enrollment assistance in accordance with requirements developed by the
Marketplace; and/or a program under which the Marketplace certifies New
York state licensed producers to provide assistance to eligible
individuals and/or small employers pursuant to federal or state law.
16. In accordance with applicable federal and state law, inform
individuals of eligibility requirements for the Medicaid program under
title XIX of the social security act and the social services law, the
children's health insurance program (CHIP) under title XXI of the social
security act and this chapter, the basic health program under section
three hundred sixty-nine-gg of the social services law, the 1332 state
innovation program in accordance with section three hundred
sixty-nine-ii of the social services law, or any applicable state or
local public health insurance program and if, through screening of the
application by the Marketplace, the Marketplace determines that such
individuals are eligible for any such program, enroll such individuals
in such program.
17. Grant a certification that an individual is exempt from the
requirement to maintain minimum essential coverage pursuant to federal
or state law and from any penalties imposed by such requirements
because:
(a) there is no affordable health plan available covering the
individual, as defined by applicable law; or
(b) the individual meets the requirements for any other such exemption
from the requirement to maintain minimum essential coverage or to pay
the penalty pursuant to applicable federal or state law.
18. Operate a small business health options program ("SHOP") pursuant
to section 1311 of the federal act and applicable state law, through
which eligible small employers may select marketplace-certified
qualified health plans offered in the small group market, and through
which eligible small employers may receive assistance in qualifying for
small business tax credits available pursuant to federal and state law.
19. Enter into agreements as necessary with federal and state agencies
and other state Marketplaces to carry out its responsibilities under
this title, provided such agreements include adequate protections with
respect to the confidentiality of any information to be shared and
comply with all state and federal laws and regulations.
20. Perform duties required by the secretary, the secretary of the
United States department of the treasury or the commissioner related to
determining eligibility for premium tax credits or reduced cost-sharing
under applicable federal or state law.
21. Meet program integrity requirements under applicable law,
including keeping an accurate accounting of receipts and expenditures
and providing reports to the secretary regarding Marketplace related
activities in accordance with applicable law.
22. Submit information provided by Marketplace applicants for
verification as required by section 1411(c) of the federal act and
applicable state law.
23. Establish rules and regulations that do not conflict with or
prevent the application of regulations promulgated by the secretary.
24. Determine eligibility, provide notices, and provide opportunities
for appeal and redetermination in accordance with the requirements of
federal and state law.
25. The commissioner is authorized to submit the appropriate waiver
applications to the United States secretary of health and human services
and/or the department of the treasury to waive any applicable provisions
of the Patient Protection and Affordable Care Act, Pub. L. 111-148 as
amended, or successor provisions, as provided for by 42 U.S.C. 18052,
and any other waivers necessary to achieve the purposes of high quality,
affordable coverage through NY State of Health, the official health plan
marketplace. The commissioner shall implement the state plans of any
such waiver in a manner consistent with applicable state and federal
laws, as authorized by the secretary of health and human services and/or
the secretary of the treasury pursuant to 42 U.S.C. 18052. Copies of
such original waiver applications and amendments thereto shall be
provided to the chair of the senate finance committee, the chair of the
assembly ways and means committee and the chairs of the senate and
assembly health committees simultaneously with their submission to the
federal government.
* 26. Subject to federal approval if required, the use of state funds
and the availability of funds in the 1332 state innovation program fund
established pursuant to section ninety-eight-d of the state finance law,
the commissioner shall have the authority to establish a program to
provide subsidies for the payment of premium or cost sharing or both to
assist individuals who are eligible to purchase qualified health plans
through the marketplace, or take such other action as appropriate to
reduce or eliminate qualified health plan premiums or cost-sharing or
both.
* NB Effective upon the commissioner of health obtaining and
maintaining certain approvals (see chapter 57 of 2024 Pt. J § 10)