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This entry was published on 2022-04-22
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SECTION 268-D
Special functions of the Marketplace related to health plan certification and qualified health plan oversight
Public Health (PBH) CHAPTER 45, ARTICLE 2, TITLE 7
§ 268-d. Special functions of the Marketplace related to health plan
certification and qualified health plan oversight. 1. Health plans
certified by the Marketplace shall meet the following requirements:

(a) The insurer offering the health plan:

(i) is licensed or certified by the superintendent or commissioner, in
good standing to offer health insurance coverage in this state, and
meets the requirements established by the Marketplace;

(ii) offers at least one qualified health plan and/or other or
additional health plans authorized for sale by the department of
financial services or the department in each of the silver and gold
levels as required by state law, provided, however, that the Marketplace
may require additional benefit levels to be offered by all insurers
participating in the Marketplace;

(iii) has filed with and received approval from the superintendent of
its premium rates and policy or contract forms pursuant to the insurance
law and/or this chapter;

(iv) does not charge any cancellation fees or penalties for
termination of coverage in violation of applicable law; and

(v) complies with the regulations developed by the secretary under
section 1311(c) of the federal act and such other requirements as the
Marketplace may establish.

(b) The health plan: (i) provides the essential health benefits
package described in state law or required by the Marketplace and
includes such additional benefits as are mandated by state law, except
that the health plan shall not be required to provide essential benefits
that duplicate the minimum benefits of qualified dental plans if:

(A) the Marketplace has determined that at least one qualified dental
plan or dental plan approved by the department of financial services or
the department is available to supplement the health plan's coverage;
and

(B) the insurer makes prominent disclosure at the time it offers the
health plan, in a form approved by the Marketplace, that the plan does
not provide the full range of essential pediatric benefits, and that
qualified dental plans or dental plans approved by the department of
financial services or department of health providing those benefits and
other dental benefits not covered by the plan are offered through the
Marketplace;

(ii) provides at least a bronze level of coverage as defined by state
law, unless the plan is certified as a qualified catastrophic plan, as
defined in section 1302(e) of the federal act and the insurance law, and
shall only be offered to individuals eligible for catastrophic coverage;

(iii) has cost-sharing requirements, including deductibles, which do
not exceed the limits established under section 1302(c) of the federal
act, state law and any requirements of the Marketplace;

(iv) complies with regulations promulgated by the secretary pursuant
to section 1311(c) of the federal act and applicable state law, which
include minimum standards in the areas of marketing practices, network
adequacy, essential community providers in underserved areas,
accreditation, quality improvement, uniform enrollment forms and
descriptions of coverage and information on quality measures for health
benefit plan performance;

* (v) meets standards specified and determined by the Marketplace,
provided that the standards do not conflict with or prevent the
application of federal requirements; and

* NB Effective until January 1, 2023

* (v) meets standards specified and determined by the Marketplace,
provided that the standards do not conflict with or prevent the
application of federal requirements;

* NB Effective January 1, 2023 until January 1, 2028

* (v) meets standards specified and determined by the Marketplace,
provided that the standards do not conflict with or prevent the
application of federal requirements; and

* NB Effective January 1, 2028

* (vi) complies with the insurance law and this chapter requirements
applicable to health insurance issued in this state and any regulations
promulgated pursuant thereto that do not conflict with or prevent the
application of federal requirements; and

* NB Effective until January 1, 2023

* (vi) contracts with any national cancer institute-designated cancer
center licensed by the department within the health plan's service area
that is willing to agree to provide cancer-related inpatient, outpatient
and medical services to enrollees in all health plans offering coverage
through the Marketplace in such cancer center's service area under the
prevailing terms and conditions that the plan requires of other similar
providers to be included in the plan's provider 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

* NB Effective January 1, 2023 until January 1, 2028

* (vi) complies with the insurance law and this chapter requirements
applicable to health insurance issued in this state and any regulations
promulgated pursuant thereto that do not conflict with or prevent the
application of federal requirements; and

* NB Effective January 1, 2028

* (vii) complies with the insurance law and this chapter requirements
applicable to health insurance issued in this state and any regulations
promulgated pursuant thereto that do not conflict with or prevent the
application of federal requirements; and

* NB Effective January 1, 2023 and Repealed January 1, 2028

(c) The Marketplace determines that making the health plan available
through the Marketplace is in the interest of qualified individuals in
this state.

2. The Marketplace shall not exclude a health plan:

(a) on the basis that the health plan is a fee-for-service plan;

(b) through the imposition of premium price controls by the
Marketplace; or

(c) on the basis that the health plan provides treatments necessary to
prevent patients' deaths in circumstances the Marketplace determines are
inappropriate or too costly.

3. The Marketplace shall require each insurer certified or seeking
certification of a health plan as a qualified health plan or plan
approved for sale by the department of financial services or the
department to:

(a) submit a justification for any premium increase pursuant to
applicable law prior to implementation of such increase. The insurer
shall prominently post the information on its internet website. Such
rate increases shall be subject to the prior approval of the
superintendent pursuant to the insurance law;

(b)(i) make available to the public and submit to the Marketplace, the
secretary and the superintendent, accurate and timely disclosure of:

(A) claims payment policies and practices;

(B) periodic financial disclosures;

(C) data on enrollment and disenrollment;

(D) data on the number of claims that are denied;

(E) data on rating practices;

(F) information on cost-sharing and payments with respect to any
out-of-network coverage;

(G) information on enrollee and participant rights under title I of
the federal act; and

(H) other information as determined appropriate by the secretary or
otherwise required by the Marketplace;

(ii) the information shall be provided in plain language, as that term
is defined in section 1311(e)(3)(B) of the federal act and state law,
and in guidance jointly issued thereunder by the secretary and the
federal secretary of labor; and

(c) provide to individuals, in a timely manner upon the request of the
individual, the amount of cost-sharing, including deductibles,
copayments, and coinsurance, under the individual's health plan or
coverage that the individual would be responsible for paying with
respect to the furnishing of a specific item or service by a
participating provider. At a minimum, this information shall be made
available to the individual through an internet website and through
other means for individuals without access to the internet.

4. The Marketplace shall not exempt any insurer seeking certification
of a health plan, regardless of the type or size of the insurer, from
licensing or solvency requirements under the insurance law or this
chapter, and shall apply the criteria of this section in a manner that
ensures a level playing field for insurers participating in the
Marketplace.

5. (a) The provisions of this article that apply to qualified health
plans and plans approved for sale by the department of financial
services and the department also shall apply to the extent relevant to
qualified dental plans approved for sale by the department of financial
services or the department, except as modified in accordance with the
provisions of paragraphs (b) and (c) of this subdivision or otherwise
required by the Marketplace.

(b) The qualified dental plan or dental plan approved for sale by the
department of financial services and/or the department shall be limited
to dental and oral health benefits, without substantially duplicating
the benefits typically offered by health benefit plans without dental
coverage, and shall include, at a minimum, the essential pediatric
dental benefits prescribed by the secretary pursuant to section
1302(b)(1)(J) of the federal act, and such other dental benefits as the
Marketplace or secretary may specify in regulations.

(c) Insurers may jointly offer a comprehensive plan through the
Marketplace in which an insurer provides the dental benefits through a
qualified dental plan or plan approved by the department of financial
services or the department and an insurer provides the other benefits
through a qualified health plan, provided that the plans are priced
separately and also are made available for purchase separately at the
same price.