§ 369-gg. Basic health program. 1. Definitions. For purposes of this
section:

(a) "Eligible organization" means an insurer licensed pursuant to
article thirty-two or forty-two of the insurance law, a corporation or
an organization under article forty-three of the insurance law, or an
organization certified under article forty-four of the public health
law, including providers certified under section forty-four hundred
three-e of the public health law;

(b) "Approved organization" means an eligible organization approved by
the commissioner to underwrite a basic health insurance plan pursuant to
this title;

* (c) "Health care services" means (i) the services and supplies as
defined by the commissioner 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 commissioner 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, and (iii) as defined by the commissioner and subject to
federal approval, certain services and supports provided to enrollees
eligible pursuant to subparagraph one of paragraph (g) of subdivision
one of section three hundred sixty-six of this article 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;

* NB Effective until December 31, 2025

* (c) "Health care services" means (i) the services and supplies as
defined by the commissioner 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 commissioner 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; and (ii) dental and vision services as defined by the
commissioner, and (iii) as defined by the commissioner 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;

* NB Effective January 1, 2026 until January 1, 2028

* (c) "Health care services" means (i) the services and supplies as
defined by the commissioner 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 commissioner for the purposes of defining
such benefits, and (ii) as defined by the commissioner 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;

* NB Effective January 1, 2028 if federal approval is withdrawn or 42
U.S.C. 18051 is repealed

(d) "Qualified health plan" means a health plan that meets the
criteria 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 health insurance exchange marketplace; and

* (e) "Basic health insurance plan" means a standard 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 this section.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

* (e) "Basic health insurance plan" means a standard health plan,
separate and apart from qualified health plans, that is issued by an
approved organization and certified in accordance with this section.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

2. Authorization. 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 basic health program. The
commissioner's authority pursuant to this section is contingent upon
obtaining and maintaining all necessary approvals from the secretary of
health and human services to offer a basic health program in accordance
with 42 U.S.C. 18051. The commissioner may take any and all actions
necessary to obtain such approvals. Notwithstanding the foregoing,
within ninety days of the effective date of the chapter of the laws of
two thousand fifteen which amended this subdivision the commissioner
shall submit a report to the temporary president of the senate and the
speaker of the assembly detailing a contingency plan in the event
eligibility rules or regulations are modified or repealed; or in the
event federal payment is reduced from ninety five percent of the premium
tax credits and cost-sharing reductions pursuant to the patient
protection and affordable care act (P.L. 111-148). The contingency plan
shall be implemented within ninety days of the above stated events or
the time period specified in federal law.

3. Eligibility. A person is eligible to receive coverage for health
care services pursuant to this title if he or she:

(a) resides in New York state and is under sixty-five years of age;

(b) is not eligible for medical assistance under title eleven of this
article or for the child health insurance plan described in title one-A
of article twenty-five of the public health law;

(c) is 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 of such code; and

* (d) (i) except as provided by subparagraph (ii) of this paragraph,
has 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; 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; however, MAGI eligible noncitizens lawfully present in
the United States 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 title if such noncitizen would be ineligible for medical assistance
under title eleven of this article due to their immigration status;

(ii) subject to federal approval and the use of state funds, unless
the commissioner may use funds under subdivision seven of this section,
has 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; however, MAGI eligible aliens lawfully present in the
United States 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 title if such alien would be ineligible for medical assistance
under title eleven of this article due to their immigration status;

(iii) subject to federal approval if required and the use of state
funds, unless the commissioner may use funds under subdivision seven of
this section, a pregnant individual who is eligible for and receiving
coverage for health care services pursuant to this title is eligible to
continue to receive health care services pursuant to this title during
the 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 title;

(iv) subject to federal approval, a child born to an individual
eligible for and receiving coverage for health care services pursuant to
this title who would be eligible for coverage pursuant to subparagraphs
(2) or (4) of paragraph (b) of subdivision 1 of section three hundred
and sixty-six of the social services law shall be deemed to have applied
for 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.

An applicant who fails to make an applicable premium payment, if any,
shall lose eligibility to receive coverage for health care services in
accordance with time frames and procedures determined by the
commissioner.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

* (d) (i) except as provided by subparagraph (ii) of this paragraph,
has 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; 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; however, MAGI eligible noncitizens lawfully present in
the United States 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 title if such noncitizen would be ineligible for medical assistance
under title eleven of this article due to their immigration status;

(ii) subject to federal approval and the use of state funds, unless
the commissioner may use funds under subdivision seven of this section,
has 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; however, MAGI eligible aliens lawfully present in the
United States 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 title if such alien would be ineligible for medical assistance
under title eleven of this article due to their immigration status;

(iii) subject to federal approval if required and the use of state
funds, unless the commissioner may use funds under subdivision seven of
this section, a pregnant individual who is eligible for and receiving
coverage for health care services pursuant to this title is eligible to
continue to receive health care services pursuant to this title during
the 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 title;

(iv) subject to federal approval, a child born to an individual
eligible for and receiving coverage for health care services pursuant to
this title who would be eligible for coverage pursuant to subparagraphs
(2) or (4) of paragraph (b) of subdivision 1 of section three hundred
and sixty-six of the social services law shall be deemed to have applied
for 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.

An applicant who fails to make an applicable premium payment shall
lose eligibility to receive coverage for health care services in
accordance with time frames and procedures determined by the
commissioner.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

4. Enrollment. (a) Subject to federal approval, the commissioner is
authorized to establish an application and enrollment procedure for
prospective enrollees. Such procedure shall include a verification
system for applicants, which shall be consistent with 42 USC § 1320b-7.

(b) Such procedure shall allow for continuous enrollment for enrollees
to the basic health program where an individual may apply and enroll for
coverage at any point.

(c) Upon an applicant's enrollment in a basic health insurance plan,
coverage for health care services pursuant to the provisions of this
title shall be prospective. Coverage shall begin in a manner consistent
with the requirements for qualified health plans offered through the
health insurance exchange marketplace, as delineated in federal
regulation at 42 CFR 155.420(b)(1) or any successor regulation thereof.

(d) A person who has enrolled for coverage pursuant to this title, and
who loses eligibility to enroll in the basic health program for a reason
other than citizenship status, lack of state residence, failure to
provide a valid social security number, providing inaccurate information
that would affect eligibility when requesting or renewing health
coverage pursuant to this title, 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 his or her
eligibility for coverage continued until the end of such twelve month
period, provided that the state receives federal approval for using
funds from the basic health program trust fund, established under
section 97-oooo of the state finance law, for the costs associated with
such assistance.

* 5. Premiums and cost sharing. (a) Subject to federal approval, the
commissioner shall establish premium payments enrollees shall pay to
approved organizations for coverage of health care services pursuant to
this title. 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.

(b) The commissioner shall establish cost sharing obligations for
enrollees, subject to federal approval. There shall be no cost-sharing
obligations for enrollees for dental and vision services as defined in
subparagraph (ii) of paragraph (c) of subdivision one of this section;
services and supports as defined in subparagraph (iii) of paragraph (c)
of subdivision one of this section; and health care services authorized
under subparagraphs (iii) and (iv) of paragraph (d) of subdivision three
of this section.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

* 5. Premiums and cost sharing. (a) Subject to federal approval, the
commissioner shall establish premium payments enrollees shall pay to
approved organizations for coverage of health care services pursuant to
this title. Such premium payments shall be established in the following
manner:

(i) up to twenty dollars monthly for an individual with a household
income above one hundred and fifty percent of the federal poverty line
but 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; and

(ii) no payment is required for individuals with a household income at
or below one hundred and 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.

(b) The commissioner shall establish cost sharing obligations for
enrollees, subject to federal approval. There shall be no cost-sharing
obligations for services and supports as defined in subparagraph (iii)
of paragraph (c) of subdivision one of this section; and health care
services authorized under subparagraphs (iii) and (iv) of paragraph (d)
of subdivision three of this section.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

6. Rates of payment. (a) The commissioner 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 title. 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
population 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 shall develop
reimbursement methodologies and fee schedules for determining rates of
payment, which rate shall be approved by the director of the division of
the budget, to be made by the department to approved organizations for
the cost of health care services coverage pursuant to this title. Such
reimbursement methodologies and fee schedules may include provisions for
capitation arrangements.

(c) The commissioner shall have the authority to promulgate
regulations, including emergency regulations, necessary to effectuate
the provisions of this subdivision.

(d) The department 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 basic health plan authorized under this section. Such report
shall be provided annually to the temporary president of the senate and
the speaker of the assembly.

* 7. Any funds transferred by the secretary of health and human
services to the state pursuant to 42 U.S.C. 18051(d) shall be deposited
in trust. Funds from the trust shall be used for providing health
benefits through an approved organization, which, at a minimum, shall
include essential health benefits as defined in 42 U.S.C. 18022(b); to
reduce the premiums, if any, and cost sharing of participants in the
basic health program; or for such other purposes as may be allowed by
the secretary of health and human services. Health benefits available
through the basic health program shall be provided by one or more
approved organizations pursuant to an agreement with the department of
health and shall meet the requirements of applicable federal and state
laws and regulations.

* NB Repealed if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

* 7. Any funds transferred by the secretary of health and human
services to the state pursuant to 42 U.S.C. 18051(d) shall be deposited
in trust. Funds from the trust shall be used for providing health
benefits through an approved organization, which, at a minimum, shall
include essential health benefits as defined in 42 U.S.C. 18022(b); to
reduce the premiums and cost sharing of participants in the basic health
program; or for such other purposes as may be allowed by the secretary
of health and human services. Health benefits available through the
basic health program shall be provided by one or more approved
organizations pursuant to an agreement with the department of health and
shall meet the requirements of applicable federal and state laws and
regulations.

* NB Effective if federal approval is withdrawn or 42 U.S.C. 18051 is
repealed

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 his or her 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. Reporting. The commissioner shall submit a report to the temporary
president of the senate and the speaker of the assembly annually by
December thirty-first. The report shall include, at a minimum, an
analysis of the basic health program and its impact on the financial
interest of the state; its impact on the health benefit exchange
including enrollment and premiums; its impact on the number of uninsured
individuals in the state; its impact on the Medicaid global cap; and the
demographics of basic health program enrollees including age and
immigration status.