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This entry was published on 2014-09-22
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SECTION 1121
Voucher insurance program
Insurance (ISC) CHAPTER 28, ARTICLE 11
§ 1121. Voucher insurance program. (a) The superintendent, in
consultation with the commissioner of health, is authorized to conduct a
program on a demonstration basis to the extent of funds available
therefor, through contractual arrangements with approved organizations,
to assist individuals and families residing in specified urban, rural or
suburban areas in purchasing health care coverage through insurers,
health maintenance organizations and integrated delivery systems.

(b) The superintendent shall designate the urban, rural or suburban
areas to be served by the voucher insurance program. The superintendent
shall determine the overall amount of funding to be allocated for
vouchers issued in designated urban, rural or suburban areas.

(c) The superintendent, in consultation with the commissioner of
health, shall establish guidelines for the submission of proposals by
organizations for the purposes of administering the voucher insurance
program including, but not limited to the following:

(1) standards for enrollment of eligible persons, including mechanisms
for determining eligibility, and annual recertification;

(2) standards for monitoring the performance of insurers, health
maintenance organizations and integrated delivery systems participating
in the voucher program; and

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

(d) A proposal submitted by an organization to administer the voucher
program shall include the following:

(1) a designation of the geographic area to be served;

(2) an estimation of the number of persons who will be eligible for
the program and the estimated number of actual participants in the
program in the specified geographic area;

(3) a description of the procedures for enrollment of eligible
individuals and families in the voucher program;

(4) a demonstration of the availability and accessibility of offices
where individuals and families could obtain information and enroll in
the voucher program;

(5) a description of the mechanisms for preventing fraudulent
enrollment;

(6) a description of the procedure for issuance of the voucher and for
monitoring individual and family enrollment in health maintenance
organizations, integrated delivery systems and insurers participating in
the voucher program;

(7) a description of the mechanisms for monitoring the performance of
health maintenance organizations, integrated delivery systems and
insurers participating in the program;

(8) a description of the procedures for marketing the voucher program
and the proposed community outreach activities including the
identification of any subcontractor who will perform these activities;

(9) a detailed description of the estimated expenses, including
personnel costs and other types of administrative expenses which will be
incurred in the development and implementation of the voucher program;

(10) a demonstration of the applicant's ability to meet the data
analysis and reporting requirements of the program;

(11) a demonstration of the financial feasibility of the program; and

(12) such other information as the superintendent may deem
appropriate.

(e) The superintendent, in consultation with the commissioner of
health, shall make a determination whether to approve, disapprove or
recommend modification to the proposal of an applicant to administer the
voucher program.

(f) An organization approved to administer the voucher program shall
submit reports to the superintendent in such form and at times as may be
required in order to facilitate evaluation of the operations and results
of the voucher program.

(g) The superintendent may approve more than one organization to
administer the voucher program in all or part of a geographic area.

(h) The superintendent shall determine the amount of funds to be
allocated to an approved organization to administer the voucher program
within such funds which are available for purposes of the voucher
program.

(i) The superintendent shall review the marketing, community outreach
activities and recruitment efforts of an organization administering the
voucher program and may provide financial incentives if certain
enrollment targets are met.

(j) An organization approved to administer the voucher program may be
subject to financial penalties established by the superintendent for
violating the standards of the voucher program. Organizations
administering the program shall also be required to repay to the state
all voucher payments issued on account of ineligible individuals or
families. An organization approved to administer the voucher program
may be removed by the superintendent as an approved organization and
must cooperate in the orderly transition of services to other approved
organizations. The superintendent shall provide due notice and an
opportunity for a hearing to an approved organization prior to
implementing this subsection.

(k) Vouchers shall be issued by the organization administering the
voucher program to eligible individuals and families residing in
designated urban, suburban or rural areas. Individuals and families
shall submit such vouchers to participating insurers, integrated
delivery systems and health maintenance organizations for the purpose of
obtaining insurance coverage.

(l) The superintendent shall establish, for those individuals and
families eligible, the voucher amounts by regulation, and shall consider
household size, gross annual income, the cost of obtaining health care
coverage through a participating insurer, integrated delivery system or
health maintenance organization and overall funding available for the
voucher program.

(m) An insurer organized to write the kind of health insurance
specified in paragraph three of subsection (a) of section one thousand
one hundred thirteen of this article, and a corporation or health
maintenance organization authorized pursuant to article forty-three of
this chapter or a health maintenance organization or integrated delivery
system certified pursuant to article forty-four of the public health law
may submit a proposal for participation in the voucher program to the
superintendent who shall consult with the commissioner of health. Such
proposal shall include:

(1) a description of the standards for provider enrollment if
applicable;

(2) a description of the geographic area to be served, an estimate of
the eligible and actual enrollees in such designated area; and a
demonstration of the benefits to the community;

(3) a demonstration of access to and delivery of high quality health
care services and, if applicable, that any network of health care
providers includes sufficient numbers of geographically accessible
providers to service program participants;

(4) a demonstration of the manner in which primary and preventive care
and medical treatment will be emphasized or substituted for hospital
inpatient or emergency room services in order to provide more
appropriate care and more cost effective use of general hospitals.

(5) a description of the procedures for marketing the program, if
applicable;

(6) a description of health care provider payment methodologies;

(7) a description of the premium in relation to the benefit package;

(8) a description of the estimated expenses including personnel costs
and other types of administrative expenses which will be incurred in the
program;

(9) a description of the quality assurance and utilization review
mechanisms to be implemented;

(10) a description of the provisions for arranging for or offering
conversion coverage in the event of termination of coverage;

(11) a demonstration of an ability to meet data analysis and reporting
requirements of the program; and

(12) such other information as the superintendent may deem
appropriate.

(n) The superintendent, in consultation with the commissioner of
health, shall make a determination whether to approve, disapprove or
recommend a modification to an insurer's, integrated delivery system's
or health maintenance organization's proposal to participate in the
voucher program.

(o) The superintendent, in consultation with the commissioner of
health, shall ensure, to the extent possible, that the voucher program
is available in designated urban, suburban or rural areas. The
superintendent may approve more than one insurer, integrated delivery
system or health maintenance organization to serve all or part of a
geographic area.

(p) An approved insurer, integrated delivery system or health
maintenance organization shall submit reports to the superintendent and
to the organization administering the voucher program in such form and
at times as may be reasonably required in order to evaluate the
operations and results of such program.

(q) An approved insurer, integrated delivery system or health
maintenance organization may be removed from participation in the
voucher program provided, however, that eligible persons shall continue
to receive coverage of services until such time as the orderly
transition to other approved insurers, integrated delivery systems and
health maintenance organizations can be effected. The superintendent
shall provide due notice and an opportunity for a hearing to an approved
insurer, integrated delivery systems or health maintenance organization
prior to implementing this subsection.

(r) Notwithstanding any inconsistent provision of law or regulation to
the contrary, benefits under the voucher program shall be considered
secondary to any other plan of insurance or benefit program under which
a person may have coverage.

(s) An insurer, integrated delivery system or health maintenance
organization may issue contracts approved by the superintendent,
providing coverage to voucher recipients, pursuant to the following
criteria:

(1) the provisions are not misleading or confusing:

(2) the provisions are consistent with the needs of the voucher
program;

(3) the materials describing the contract fully and clearly state the
benefits and limitations of such contract;

(4) the duration of such contracts and the extent of exposure
thereunder by insurers, article forty-three corporations, integrated
delivery systems or health maintenance organizations shall be determined
by the superintendent;

(5) the contract is a reasonable and appropriate approach to expand
the availability of health care coverage;

(6) the funding for the contract is reasonably related to the benefits
provided and sufficient to support the contract;

(7) any such contracts must include the preexisting condition
provisions permitted by section three thousand two hundred thirty-two
and section four thousand three hundred eighteen of this chapter as
applicable; and

(8) notwithstanding any provisions of this chapter to the contrary,
the superintendent may waive, modify or suspend any provisions of this
chapter, except as to mandatory benefits, or department regulations as
applicable to the insurers, article forty-three corporations, integrated
delivery systems or health maintenance organizations which issue
coverage pursuant to this section, provided such waiver, modification or
suspension is based on the following:

(A) any waiver, modification or suspension of provisions of this
chapter or department regulations is essential to the operation of the
voucher program and to the rational development of programs to provide
health care coverage or equivalent coverage mechanisms to the uninsured;
and

(B) any waiver, modification or suspension of provisions of this
chapter or department regulations will not impair the ability of the
insurer, article forty-three corporation, integrated delivery system or
health maintenance organization to satisfy its existing and anticipated
contracts and other obligations, including such standards as the
superintendent shall prescribe concerning adequate capital and financial
requirements.

(t) The contracts issued by insurers, integrated delivery systems or
health maintenance organizations and approved by the superintendent
providing coverage to voucher recipients must provide for only the
following covered services:

(1) Outpatient diagnostic X-ray and lab services;

(2) Outpatient surgical services including anesthesia;

(3) Mammography screening.

(4) Cervical cytology screening.

(5) Well-child care from birth.

(6) Primary and preventive care services.

(u) In order to be eligible to purchase coverage under the voucher
program, the individual or family shall meet the following criteria:

(1) reside or resides in a household having a gross household income
at or below two hundred twenty-two percent of the non-farm federal
poverty level (as defined and annually revised by the federal office of
management and budget). An applicant shall provide the necessary
documentation to initially, and annually thereafter, determine
eligibility for a voucher. Such documentation shall include the latest
annual income tax return. If no such income tax return has been filed
or if the household income has changed since the date of the return,
such documentation shall also include, but not be limited to: paycheck
stubs; written documentation of income from all employers; or other
documentation of income (earned or unearned) as determined by the
superintendent, provided however, such documentation shall set forth the
source of such income;

(2) is not eligible for medical assistance under title eleven of
article five of the social services law or for medicare pursuant to
title eighteen of the federal social security act;

(3) does not have equivalent health care coverage as defined by the
superintendent. The applicant shall attest to the source and nature of
health care coverage available;

(4) is a resident of a designated urban, suburban or rural area in New
York state. Such residency shall be demonstrated by adequate proof of a
New York state street address or if the individual or family has no
street address, then by other such proof;

(5) has not had equivalent health care coverage within the twelve
month period prior to application for a voucher. This limitation shall
not apply to persons who became ineligible for medical assistance or
whose insurance terminated as a result of loss of employment within such
period;

(6) the individual or family shall notify the organization
administering the voucher program within sixty days, of any changes in
income, health care coverage or residency that may make them ineligible
for the voucher program; and

(7) any individual or family who, with the intent to obtain benefits,
willfully misstates income or residence or other health care coverage to
establish eligibility or willfully fails to notify an organization
administering the voucher program of an increase in income or change in
residence or health care coverage which may disqualify the individual or
family for benefits shall repay such subsidy. Individuals seeking to
enroll in the voucher program shall be informed that such willfull
misstatement or failure to notify shall result in such liability.

(v) Nothing in this section shall be construed to provide a right or
entitlement to insurance coverage, or a cause of action or right of
action to eligible individuals and families, approved organizations, or
providers of health care services for the provision of or payment for
such services relating to the availability or implementation of
insurance coverage under this section.

(w) The superintendent shall implement such requirements or procedures
as necessary to prevent, detect and deter fraud and abuse in the voucher
insurance program.