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  5. Title 7: Ny State of Health


Section 268-D Special functions of the Marketplace related to health plan certification and qualified health plan oversight

Public Health (PBH)

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

  (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

  (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.