369-EE - Family health plus program.
§ 369-ee. Family health plus program. 1. Definitions. (a) "Family health insurance plan" means the written undertaking of an approved organization to provide coverage of health care services to eligible individuals under this title. (b) "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 such article. (c) "Approved organization" means an eligible organization which has been approved by the commissioner to underwrite a family health insurance plan. (d) "Period of eligibility" means that period commencing on the first day of the month following the date when the individual (i) has been determined eligible for health care coverage under this title and (ii) has enrolled in a family health insurance plan, and ending on the last day of the month in which an individual ceases to be eligible. (e) "Health care services" means the following services and supplies as defined by the commissioner in consultation with the superintendent of insurance, except as provided in subdivision three-a of this section: (i) the services of physicians, nurse practitioners, and other related personnel which are provided on an outpatient or inpatient basis; (ii) inpatient hospital services provided by a general hospital, a facility operated by the office of mental health under section 7.17 of the mental hygiene law, a facility issued an operating certificate pursuant to the provisions of article twenty-three or thirty-one of the mental hygiene law; (iii) laboratory tests; (iv) diagnostic x-rays; (v) prescription drugs as defined in section two hundred seventy of the public health law, which shall be provided pursuant to subdivision two-b of this section, and non-prescription smoking cessation products or devices; (vi) durable medical equipment; (vii) radiation therapy, chemotherapy, and hemodialysis; (viii) emergency room services; (ix) inpatient and outpatient mental health and alcohol and substance abuse services, as defined by the commissioner; (x) prehospital emergency medical services for the treatment of an emergency medical condition when such services are provided by an ambulance service; (xi) emergency, preventive and routine dental care, to the extent offered by a family health insurance plan described in this section, except orthodontia and cosmetic surgery; (xii) emergency vision care, and preventive and routine vision care as follows: once in any twenty-four month period: (A) one eye examination; (B) either: one pair of prescription eyeglass lenses and a frame, or prescription contact lenses where medically necessary; and (C) one pair of medically necessary occupational eyeglasses; (xiii) speech and hearing services; (xiv) diabetic supplies and equipment; (xv) services provided to meet the requirements of 42 U.S.C. 1396d(r); and (xvi) hospice services. (e-1) "Health care services" shall not include: (i) drugs, procedures and supplies for the treatment of erectile dysfunction when provided to,or prescribed for use by, a person who is required to register as a sex offender pursuant to article six-C of the correction law provided that any denial of coverage pursuant to this paragraph shall provide the patient with the means of obtaining additional information concerning both the denial and the means of challenging such denial; (ii) drugs for the treatment of sexual or erectile dysfunction, unless such drugs are used to treat a condition, other than sexual or erectile dysfunction, for which the drugs have been approved by the federal food and drug administration. (f) "Managed care provider" shall have the meaning set forth in section three hundred sixty-four-j of this article. (g) "Minor child" means, for purposes of this title, a child under the age of twenty-one. (h) "Commissioner" for purposes of this title shall mean the commissioner of health. 2. Eligibility. (a) A person is eligible to receive health care services pursuant to this title if he or she: (i) resides in New York state and is at least age nineteen, but under sixty-five years of age; (ii) is not eligible for medical assistance under title eleven of this article solely due to income or resources or is eligible for medical assistance under title eleven of this article only through the application of excess income toward the costs of medical care and services pursuant to subdivision two of section three hundred sixty-six of title eleven of this article; * (iii) does not have equivalent health care coverage under insurance or equivalent mechanisms, as defined by the commissioner in consultation with the superintendent of insurance; * NB Effective until amendment approved by the commissioner of health * (iii) does not have equivalent health care coverage under insurance or equivalent mechanisms, as defined by the commissioner in consultation with the superintendent of insurance; * NB Effective upon approval by the commissioner of health * (iv) (A) was not covered by a group health plan based upon his or her employment or a family member's employment, as defined by the commissioner in consultation with the superintendent of insurance, during the six month period prior to the date of the application under this title, except in the case of: (I) loss of employment due to factors other than voluntary separation; (II) death of a family member which results in termination of the applicant's coverage under the group health plan; (III) change to a new employer that does not provide an option for comprehensive health benefits coverage; (IV) change of residence so that no employer-based comprehensive health benefits coverage is available; (V) discontinuation of comprehensive health benefits coverage to all employees of the applicant's employer; (VI) expiration of the coverage periods established by COBRA or the provisions of subsection (m) of section three thousand two hundred twenty-one, subsection (k) of section four thousand three hundred four and subsection (e) of section four thousand three hundred five of the insurance law; (VII) termination of comprehensive health benefits coverage due to long-term disability; (VIII) loss of employment due to need to care for a child or disabled household member or relative; or (IX) reduction in wages or hours or an increase in the cost of coverage so that coverage is no longer affordable or available.(B) the implementation of this subparagraph shall take effect only upon the commissioner's finding that insurance provided under this title is substituting for coverage under group health plans in excess of a percentage specified pursuant to subparagraph (ii) of paragraph (d) of subdivision two of section twenty-five hundred eleven of the public health law. * NB Effective until amendment approved by the commissioner of health * (iv) (A) was not covered by a group health plan based upon his or her employment or a family member's employment, as defined by the commissioner in consultation with the superintendent of insurance, during the nine-month period prior to the date of the application under this title, except in the case of: (I) loss of employment due to factors other than voluntary separation; (II) death of a family member which results in termination of the applicant's coverage under the group health plan; (III) change to a new employer that does not provide an option for comprehensive health benefits coverage; (IV) change of residence so that no employer-based comprehensive health benefits coverage is available; (V) discontinuation of comprehensive health benefits coverage to all employees of the applicant's employer; (VI) expiration of the coverage periods established by COBRA or the provisions of subsection (m) of section three thousand two hundred twenty-one, subsection (k) of section four thousand three hundred four and subsection (e) of section four thousand three hundred five of the insurance law; (VII) termination of comprehensive health benefits coverage due to long-term disability; (VIII) loss of employment due to need to care for a child or disabled household member or relative; or (IX) reduction in wages or hours or an increase in the cost of coverage so that coverage is no longer affordable or available. (B) the implementation of this subparagraph shall take effect only upon the commissioner's finding that insurance provided under this title is substituting for coverage under group health plans in excess of a percentage specified pursuant to subparagraph (ii) of paragraph (d) of subdivision two of section twenty-five hundred eleven of the public health law. * NB Effective upon approval by the commissioner of health (v) (A) in the case of a parent or stepparent of a child under the age of twenty-one who lives with such child, has gross family income equal to or less than the applicable percent of the federal income official poverty line (as defined and updated by the United States Department of Health and Human Services) for a family of the same size; for purposes of this clause, the applicable percent effective as of: (I) January first, two thousand one, is one hundred twenty percent; and (II) October first, two thousand one, is one hundred thirty-three percent; and (III) October first, two thousand two, is one hundred fifty percent; and (IV) April first, two thousand ten, is one hundred sixty percent; or (B) in the case of an individual who is at least twenty-one years of age and who is not a parent or stepparent living with his or her child under the age of twenty-one, has gross family income equal to or less than one hundred percent of the federal income official poverty line (as defined and updated by the United States Department of Health and Human Services) for a family of the same size; or(C) in the case of an individual who is at least nineteen but under twenty-one years of age and who is not a parent or stepparent living with his or her child under the age of twenty-one, has gross family income equal to or less than one hundred sixty percent of the federal income official poverty line (as defined and updated by the United States Department of Health and Human Services) for a family of the same size; or (D) is not described in clause (A), (B) or (C) of this subparagraph and has gross family income equal to or less than two hundred percent of the federal income official poverty line (as defined and updated by the United States Department of Health and Human Services) for a family of the same size; provided, however, that eligibility under this clause is subject to sources of federal and non-federal funding for such purpose described in section sixty-seven-a of the chapter of the laws of two thousand nine that added this clause or as may be available under the waiver agreement entered into with the federal government under section eleven hundred fifteen of the federal social security act, as jointly determined by the commissioner and the director of the division of the budget. In no case shall state funds be utilized to support the non-federal share of expenditures pursuant to this subparagraph, provided however that the commissioner may demonstrate to the United States department of health and human services the existence of non-federally participating state expenditures as necessary to secure federal funding under an eleven hundred fifteen waiver for the purposes herein. Eligibility under this clause may be provided to residents of all counties or, at the joint discretion of the commissioner and the director of the division of the budget, a subset of counties of the state. (b) Subject to the provisions of paragraph (d) of this subdivision, in order to establish eligibility under this subdivision, which shall be determined without regard to resources, an individual shall provide such documentation as is necessary and sufficient to initially, and annually thereafter, determine an applicant's eligibility for coverage under this title. Such documentation shall include, but not be limited to the following, if needed to verify eligibility: (i) paycheck stubs; or (ii) written documentation of income from all employers; or (iii) other documentation of income (earned or unearned) as determined by the commissioner, provided however, such documentation shall set forth the source of such income; and (iv) proof of identity and residence as determined by the commissioner. The commissioner of health may verify the accuracy of the information provided by the individual pursuant to this paragraph by matching it against information to which the commissioner of health has access including under subdivision eight of section three hundred sixty-six-a of this article. * (b-1) Notwithstanding the provisions of paragraph (b) of this subdivision, an individual may attest to the amount of interest income generated by his or her accumulated resources if the amount of such interest income is expected to be immaterial to eligibility under this section, as determined by the commissioner of health. In the event there is an inconsistency between the information reported by the individual and any information obtained by the commissioner of health from other sources and such inconsistency is material to eligibility under this section, the commissioner of health shall request that the individual provide adequate documentation to verify his or her interest income. * NB Effective November 1, 2010* (d) In order to establish place of residence and income eligibility under this title at recertification, a recipient of assistance under this title shall attest to place of residence and to all information regarding the household's income that is necessary and sufficient to determine such eligibility. The commissioner of health shall verify the accuracy of the information provided by the recipient pursuant to this paragraph by matching it against information to which the commissioner of health has access, including under subdivision eight of section three hundred sixty-six-a of this article. In the event there is an inconsistency between the information reported by the recipient and any information obtained by the commissioner of health from other sources and such inconsistency is material to eligibility under this title, the commissioner of health shall request that the recipient provide adequate documentation to verify his or her place of residence or income, as applicable. In addition to the documentation of residence and income authorized by this paragraph, the commissioner of health is authorized to periodically require a reasonable sample of recipients to provide documentation of residence and income at recertification. The commissioner of health shall consult with the medicaid inspector general regarding income and residence verification practices and procedures necessary to maintain program integrity and deter fraud and abuse. * NB There are 2