369-FF - Employer partnerships for family health plus.
§ 369-ff. Employer partnerships for family health plus. 1. (a) An employer or other designated sponsor may elect to offer family health plus insurance plans approved under the family health plus program to all employees or members and family members of employees or members. If an employer or other designated sponsor chooses to offer family health plus insurance plans, the employer or other designated sponsor shall pay to the commissioner or the commissioner's designee a sum of money equal to at least seventy percent of the premium or a fixed dollar amount, as determined by the commissioner, applicable to each enrolling employee or member. Each employee or member who enrolls shall, through the employer or other designated sponsor, pay to the commissioner or the commissioner's designee the balance of the premium. If the employee's or member's share of the premium is covered by the employer sponsored health coverage or premium assistance programs set forth in this title, title eleven of this article, or title one-A of article twenty-five of the public health law, then the employee's or member's share of the premium shall be paid under such program. Notwithstanding any provision of law, rule or regulation to the contrary, the commissioner may, for children under the age of twenty-one, require family health plus insurance plans to cover all benefits covered under title one-A of article twenty-five of the public health law. (b) Where an employer or other designated sponsor chooses to offer family health plus insurance plans under this section, such employer or other designated sponsor shall disseminate to all employees or members information regarding employer sponsored health coverage or premium assistance programs set forth in this title, title eleven of this article, or title one-A of article twenty-five of the public health law. The information shall be provided by the commissioner to employers or other designated sponsors offering family health insurance plans and disseminated by employers or other designated sponsors to employees or members in a form and manner specified by the commissioner. (c) Subject to federal approval, an employer or other designated sponsor choosing to offer family health plus insurance plans in accordance with paragraph (a) of this subdivision which (i) did not previously offer health insurance to its employees or members or (ii) currently offers health insurance to its employees or members but the employer's or other designated sponsor's ability to continue to offer such coverage is in jeopardy, as determined by the commissioner, may be eligible for state subsidies towards the cost of its share of the premium only for employees or members who otherwise may be eligible for family health plus, child health plus or medical assistance under this title, title one-A of article twenty-five of the public health law or title eleven of this article, respectively. An employee or member identified as potentially eligible for family health plus, child health plus or medical assistance through a process specified by the commissioner shall apply to the appropriate program for an eligibility determination. The availability and amount of state subsidies provided pursuant to this paragraph and eligibility criteria for such subsidies shall be determined by the commissioner. State subsidies pursuant to this paragraph shall be cost effective relative to payments made under the family health plus, child health plus and medical assistance programs, whichever program is applicable. (d) All moneys paid to the commissioner under this section shall be deposited by the commissioner in the family health plus employer partnership account established under section ninety-one-g of the state finance law. Notwithstanding any provision of law, rule or regulation to the contrary, the commissioner may issue a request for proposals andenter into one or more contracts to administer the billing and collection of premiums due under this section. (e) The commissioner or the commissioner's designee is authorized to act as a health plan coordinator between employers or other designated sponsors and health plans if the commissioner determines that a health plan coordinator will be helpful in the effective implementation of this section or in facilitating the offering of multiple health plans by employers or other designated sponsors to their employees or members. The commissioner is also authorized to amend existing facilitated enrollment contracts if necessary to implement this section. (f) For purposes of this section, the term "other designated sponsor" means: a Taft-Hartley fund or a voluntary employee benefit association established in accordance with the requirements of section 501(c)(9) of the federal internal revenue code. 2. Individuals enrolled in family health plus plans under this section shall not count towards the percentage specified in clause (B) of subparagraph (iv) of paragraph (a) of subdivision two of section three hundred sixty-nine-ee of this title or towards the percentage specified in subparagraph (ii) of paragraph (d) of subdivision two of section twenty-five hundred eleven of the public health law. 3. Coverage under this section shall be community rated and the underwriting of such coverage shall involve no more than the imposition of a pre-existing condition limitation as permitted by the insurance law. Any employee or member or family member of an employee or member applying for coverage under such paragraph must be accepted by the plan at all times throughout the year and cannot be terminated due to claims experience. Termination of coverage may be based only on one or more of the reasons set forth in subsection (c) of section four thousand three hundred four or subsection (j) of section four thousand three hundred five of the insurance law. For the purposes of this subdivision, "community rated" means a rating methodology in which the premium for all persons covered by a policy or contract form is the same, based on the experience of the entire pool of risks covered by that policy or contract form without regard to age, sex, health status or occupation except that the pool of risks shall exclude individuals enrolled in a family health plus insurance plan under section three hundred sixty-nine-ee of this title if required by federal regulations governing actuarial soundness for Medicaid managed care premium rates. This subdivision does not prohibit the use of premium rate structures to establish different premium rates for individuals as opposed to family units. The premium or premiums for coverage under paragraphs (a) and (c) of subdivision one of this section shall be established by the commissioner. 4. The state share of the cost of coverage provided pursuant to paragraph (c) of subdivision one of this section shall be funded within amounts appropriated for this purpose. * 5. (a) Individuals enrolled in family health plus insurance plans under this section who are not otherwise eligible for family health plus under section three hundred sixty-nine-ee of this title shall be responsible to make co-payments in accordance with the terms of paragraph (b) of this subdivision; provided however that the total amount of any co-payments which an individual shall be required to make may not exceed two thousand dollars per annum. (b) Co-payments may be charged in the following amounts: (i) the co-payment charged for each discharge for inpatient care may be up to one hundred fifty dollars; (ii) The co-payment charged for each emergency room visit may be up to fifty dollars;(iii) the co-payment charged for each outpatient surgery may be up to one hundred dollars; (iv) the co-payment charged for each primary care physician office visit, for each dental service visit, for each laboratory service, for each radiology service, for each outpatient mental health service, and for each outpatient substance abuse service may be up to ten dollars; (v) the co-payment charged for each physician specialist service office visit, for each physical therapy service, for each occupational therapy service, for each speech therapy service, for each hearing service, for each vision service, and for each podiatric service may be up to twenty-five dollars; and (vi) the co-payment charged for each generic prescription drug dispensed may be up to five dollars and for each brand name prescription drug dispensed may be fifteen dollars. (c) An individual who is eligible for coverage under a family health plus insurance plan pursuant to section three hundred sixty-nine-ee of this title shall make co-payments in accordance with such section three hundred sixty-nine-ee and shall not make co-payments as provided in paragraph (b) of this subdivision. (d) An employer or designated sponsor participating in the family health plus program on or before July first, two thousand ten, or an employer or other designated sponsor who entered into a memorandum of understanding with the state on or before July first, two thousand ten with respect to the purchase of health insurance coverage under this section for child care providers represented by such sponsor, shall have the option to establish co-payments in accordance with section three hundred sixty-nine-ee of this title or to establish co-payments as provided in paragraph (b) of this subdivision. * NB Effective January 1, 2011 * 6. Notwithstanding any law, rule or regulation to the contrary, the commissioner may amend the application requirements for employees who may be eligible for family health plus insurance plans to limit and simplify application documentation requirements, provided however, such application requirements shall otherwise comply with federal law. * NB Effective January 1, 2011 * 7. Where a health care service under a family health plus insurance plan is not covered under a payment rate methodology agreement negotiated with a general hospital, the rate of payment for emergency and inpatient hospital services shall be in accordance with subparagraph (i) of paragraph (a-2) of subdivision one of section twenty-eight hundred seven-c of the public health law. * NB Effective January 1, 2011 * 8. An employer or other designated sponsor shall not be eligible to offer family health plus insurance plans pursuant to this section if such employer or other designated sponsor has provided health coverage during the six-month period prior to application for a group of employees. This prohibition shall not apply to: (a) an employer or other designated sponsor which employs fewer than fifty-one employees and has expenditures for health coverage of more than fifteen percent of its payroll; (b) a qualifying small employer or sole proprietor enrolled in insurance coverage pursuant to section forty-three hundred twenty-six of the insurance law; (c) an employer or other designated sponsor participating in the program on or before July first, two thousand ten; or (d) an employer or other designated sponsor who entered into a memorandum of understanding with the state on or before July first, twothousand ten with respect to the purchase of health insurance coverage under this section for child care providers represented by such sponsor. * NB Effective January 1, 2011