Legislative

Bill Drafting Commission 12048-06-1

IN SENATE
Senate The senators of this whose names are prQPoaal
s44

___
introducer
I

c signature
to join me in the sponsorship

circled

below wish

S.

s2D~

Farley

sse

Kennedy

s1B

MoD.tgomery

523 Savino s28 Serr~o sSl a09

S~4

Senate

s1S Ad.dabbo 855 Alesi 811 Avell.a s40 Ball

a02 FlanagaIl 80 t) FuBehillc s59 GallivaD. s1.2 GianiU"is 522 GQlden 947 Griffo 860 Grisanti 806 Hl!.nnOil s36 HassellTbo~son s10 Huntley
504 Johnson

s3~ Klein s26 krueger 627 Kruger

624 Lanza

854 Nozzolio 853 O'Mara 837 Opperalle.imer

Seward

sxercs
Smith

IN SENATE--Introduced

by Sen

642 neeeete &46 Breslin s38 Carlucci s50 »eeeeee+see

839 Larkin sOl LaVall.e 652 Libous. 845 Little s05 Marcellino s07 Martins 862 Maziarz
943 McDona.ld

&13 Peralta
s30

s25

Squadron

Perkins

s1.6 Stav!sky s3.5 Stewart.Cousins

849

s61 R-an'zenho£eJ:' s48 Ritchie 833 Rivera

--read twice and ordered printed, and when printed to be committed to the Committee on

83.2 Diaz li17 DilaD. 5:29 Duane 831 Espaillat

Valesky

a57 ycnwgEl~l Sal and s03 Zeldin

sas

SampSOIl

--------

A.

IN ASSEMBLY
ABaembl.y introducer's The Kembers of the A.aBem"bly waoae aemee eee circled signature below wish cc join

___
me ill the

Assembly
multi-sponsorship

of this proposal: al07 Crouch a095 Jaffee a057 .Jeffries a038 Miller, a052 Millman a103 Molinaro
1'1015 MOntesano

IN ASSEMBLY--Introduced

by M. of A.

08.049Abbate ~092 Abin~ti al05 a084 Amedore Arroyo

Aubry

K.

eo 12
al13

Sall1dino Sayward

01'1014 Curran a063 CUsick. a045 Cyinbrowit:z &'034 DenDekke.r 80081 Dinowitz al-14 Duprey
aO O~

01'1135 Johns al~2 Jordan

80029 Scarborough &016 Schimel a140 Sch.iJ:mdnger

with M. of A. as co-sponsors

a035

aDS'S!Katz 15.074 Kavanagh a065 alOO a129 a025 Ke:11ne.r

K.irwan

a132 Morelle· a039 Moya

aDO] M.urray

e.124 Barcl.ay 800-40Barron 0082 Benedetto a073 Bing

a145 seereeeee a064 Silver a036 SimotaB

Englebright

a037 Nolan alia Oaks

a071 Farrell a123 Finch

K-olb Lancma.n

a~46 Smn.rdz a093 SpaDO

--read once and referred to the Committee on

;es.1:22 Blankenbuah a055 Boyland aOOS Boyle a026 Braunstein

a069 O'Donnell aOS1

fI.}.36

a007 Pitzpatrick aD? Friend

a091 Latimer aO:1..3l..avi_ne a050 Le.nt.ol a,125 Lifton

oee Is
palmesllllo

a079 Stevenson
a0:11 SWE!&ney

a143 Gabrys:!:ak a09D Gale.f a13::. Ganl;t a077 GibsOD

aOBB Paulin a141

seopaee-

allO

TediBco

(Establishes the Benefit Exchange)

* PUBAUTLA *

a044 Breonan

15.115 Tenney a002 a061 a03l a062 :thie.le Titone Titus Tobacco

New

York

Health

a13 1 Bronson fl046 Brook-Krasny aU 7 Burling all? a101 Butler Cfl.hi~l

Stokes a127 a053 Lopez, Lopez. P. v• a05B Perry a087 Fretlow 8.021 Ra a097 Racbitt

a149 Giglio ,,066 Glick alSO Goodell a075 Gottfried

.aOO LQsquadro 1 a126 alll Lupardo Magee

aD41 Weinst.ein
aO.20 wei.senberg

Pub Aut. NY Health Benefit Exchan AN ACT to amend the public authorities law, the insurance law, and the public officers law, in relation to the establishment of the New York Health Benefit Exchange The People of the State of York, represented in Senate Assembly, do enact as follows: New and

a096 Calhoun

aOOS Raia a006

Ramos

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a,106 C.ane:st.rari a08"9 Castel..li evas cesta-c a138 Cereteo a033 C~ark a047 Colton a010 Conte
a032

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Mai.sel

a024 Weprin 01'1070 rigbt W 8.094 Zebrowski

a099 Gunther a130 Hanna

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.a134 Reil"ich al09 Reilly

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Markey McDonough McEneny

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a068 ;Rodrigue~ O. J. aOS7 R.csE!nt:h&.l al.lB Russe.ll

a142

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a042 Jacobs

1) Single. houses), bill.

House Bill

(introdu-c::ed

and p~inted

separately houses

in

either

or both as one

Oni.-;Bi_ll Senate

{introduced

simule.a.neous1y sign the

10 both

and printed
the

and Assembly

introducer

same copy of to

bill}. clerk with 2 Signed

2} Circle copies copies of bill of bill

names of co-sponsors and 4 copies

and

and return

introdu.c.ti-on {single

of :m.erncrandumin of meJrOrandum io

support support

house); .

or 4 signe.d

8 copies

<uni -bill)

LBDC

05/12

/n

05/31/11

12048-06-1

1 2 3 4 5 6

Section Health

1.

This act shall be known Exchange Act".

and may be cited as the "New York

Benefit

S 2. The public

authorities

law is amended

by

adding

new

article

10-E to read as follows: ARTICLE NEW YORK HEALTH Section 3980. Statement of policy 10-E EXCHANGE

BENEFIT

7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

and purposes.

3981. Definitions. 3982. Establishment 3983. General powers of the New York health of the exchange. benefit exchange.

3984. Functions

of the exchange. functions of the eXChange related to health plan

3985. Special

certification 3986. Advisory 3987. Funding 3988. Studies,

and qualified

health

plan oversight.

committee. of the exchange. findings and recommendations. by the state.

3989. Tax exemption 3990. Officers

and tax contract

and employees. of liability; for federal indemnification. funding.

3991. Limitation 3992. Contingency

3993. Construction.
§ 3980.

Statement

of policy an

and purposes. health

The purpose exchange

of this

article

is

to

establish

American

benefit

in New York, in
care act, recon-

conformance Public

with the federal

patient

protection

and affordable

Law 111-148, act

as amended

by the health Law 111-152.

care and

education

ciliation

of 2010, Public

The exchange the purchase

shall faciliand sale of

tate enrollment qualified health

in public health coverage,

plans

in the individual

market

in this state, and shall

05/31/11

12048-06-1

1 2 3 4

incorporate qualified qualified the

small business

health

options

program

("SHOP")

to assist in

employers health

in facilitating

the enrollment

of their employees

plans offered through

in the group market.

It is the intent of to promote number of

legislature,

the establishment coverage

of the exchange, the educate

5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

quality

and affordable persons,

health

and care, reduce marketplace, premium addition,

uninsured and assist credits declares health

provide

a transparent

consumers tax

individuals

with access

to coverage, In

assistance

and

cost-sharing

reductions.

the legislature with public health

its intent that the exchange including medicaid,

be properly child health

integrated

coverage,

plus and family

plus.
S 3981. Definitions. nitions shall apply: means the board of directors of the For purposes of this article, the following defi-

1. "Board" or "board of directors" exchange. 2. "Advisory advisory committee" means

the New pursuant

York

health

benefit

exchange

committee

established means means

to this article. of health. exchange established

3. "Commissioner" 4. "Exchange"

the commissioner

the New York health benefit

pursuant

to this article. act" means the patient protection and affordable care act, reconor guid-

5. "Federal public

law 111-148,

as amended

by the health law 111-152,

care and

education

ciliation ance issued

act of 2010, public thereunder.

and any regulations

6. "Health plan" means a policy, issued by an insurer to provide,

contract deliver,

or certificate, arrange

offered

or

for, pay for or reimplan shall not

burse any of the costs of health include the following:

care services.

Health

05/31/11

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 of

(al accident tion thereofj (b) coverage (c)

insurance

or disability

income

insurance,

or any combina-

issued as a supplement insurance,

to liability~insurancei general liability insurance and

liability

including

automobile

liability

insurance; or similar insurancej Insurance;

(d) workers'

compensation no-fault

(el automobile (f) credit

insurance; insurance coverage, as specified in federal regu-

(g) other similar lations, dental under

which

benefits

for medical

care are secondary

or inci-

to other

insurance

benefits; benefits, benefits for long-term or any health are

(h) limited care

scope dental or vision nursing home

insurance,

insurance, similar,

home care insurance, limited benefits

combination insurance provided

thereof, as

or such in

other federal

specified

regulations,

if the benefits of

under a separate

policy,

certificate

or contract

insurance

or are otherwise (i) nity, coverage

not an integral

part of the plan; disease or illness, hospital indem-

only for a specified

or other fixed indemnity supplemental

coverage; as defined in section 1882(g)(1)

(j) Medicare the federal

insurance

social security

act, coverage

supplemental

to the covercode, plan or

age provided similar

under chapter

55 of title

10 of the United under

States

supplemental

coverage policy,

provided

a group health of

if it

is offered or (k) article the

as a separate

certificate

or contract

insurance;

medical

indemnity

fund established health law.

pursuant

to title

four of

twenty-nine-D

of the public

05/31/11

12048-06-1

1 2
3

7. "Insurer" or forty-three

means

an insurance

company

subject

to article

thirty-two organizahealth arrange, law pay

of the insurance pursuant to article

law, or a health maintenance forty-four of the public deliver,

tion certified that contracts

4 5

or offers

to contract

to provide,

or reimburse

any of the costs of health dental plan" means

care services. scope dental plan with section that is thirty-

6
7 8

8.

"Qualified

a limited

issued by an insurer nine hundred

and certified

in accordance

eighty-five employer"

of this article. means a small employer for one that elects to make its health plans

9 10
11

9. "Qualified
full-time through

employees

eligible

or more gualified

the exchange. health plan" means in a health plan that is issued thirty-nine by an

12
13

10. "Qualified
insurer and

certified

accordance

with section

hundred

14 15
16 17

eighty-five

of this article. individual" means an individual, including a minor,

11. "Qualified
who: (al viduals is

seeking

to enroll

in a qualified

health plan offered

to indi-

18
19 20 21 22

through

the exchange;

(bl resides

in this state; is not incarcerated, of charges; expected and for other than incar-

(c) at the time of enrollment, ceration (d) which pending and the disposition is reasonably

is,

to be, for the entire period of the United

23 24 25 26
27

enrollment

is sought, a citizen present

or national States.

States

or an alien

lawfully

in the United

12. "Secretary" health and human

means

the secretary

of the United

States

department

of

services. the small business employers health options program designed to

13. "SHOP" means assist gualified

28

in this state

in facilitating

the enrollment

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

12048-06-1

of their employees in qualified health plans offered in the group market in this state. 14. "Small employer" means, for plan years prior to January first, two thousand sixteen, an employer that employed an average of at least one preceding

but not more than fifty employees on business days during the calendar

year. For plan years beginning on and after January first, two an employer that employed an

thousand sixteen, small employer means

average of at least one but not more than one hundred employees on business days during the preceding calendar year. For purposes of the defi-

nition of small employer: (al all persons treated as a single (cl, (m) or
(0) of

employer

under

subsection

(bl,

section 414 of the Internal Revenue Code of 1986

shall be treated as a single employer; (b) an employer and any predecessor employer shall single employer; (cl all employees shall be counted, including part-time employees and be treated as a

employees who are not eligible for coverage through the employer; (d) if an employer was' not calendar year, then the in existence throughout the preceding

determination

of whether that e~ployer is a that

small employer shall be based upon the average number of employees the employer reasonably expects to employ on

business days in the

current calendar year; eel if a gualified employer that makes enrollment in gualified plans available to its health

employees through the exchange ceases to be a employees,

small employer by reason of an increase in the number of its then the

employer shall continue to be treated as a gualified employer increase

for purposes of this article for the period beginning with the

05/31/ll 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 of and ending

12048-06-1

with the first day on which the employer does not make such

enrollment available to its employees~ and (f) an employer also shall be considered a small employer if the coverage under the

coverage it offers would be considered small group

insurance law and regulations promulgated thereunder provided that it is not otherwise prohibited under the federal act. 15. "Small group market" means the health insurance market under which individuals receive health insurance coverage on behalf of themselves a small

and their dependents through a group health plan maintained by employer. 16. "State meditaid director" shall mean

the employee or officer

designated by the commissioner as the state medicaid director. 17. "Superintendent" means the superintendent of insurance until October third, two thousand eleven, when such term intendent of financial services. S 3982. Establishment of the New York health benefit exchange. 1. the shall mean the super-

There is hereby created a public benefit corporation to be known as New York health benefit exchange. Such

corporation shall be a body

corporate and politic. 2. The purpose of the exchange is to facilitate the purchase and qualified health sale

plans, assist qualified employers in facilitating the

the enrollment of their employees in qualified health plans through

small business health options program, and carry out other functions set forth in this article. 3. (a) The exchange shall be governed by a board of directors consist-

ing

of

seven

voting directors, including the commissioner, the superoffi-

intendent, and the state medicaid director, who shall serve as ex cio directors.

05/31/11

12048-06-1

1 2 3 4 5 6

(b)

Four

directors upon

shall

be appointed

by the governor, of the temporary

one of whom president of by

shall be appointed

the recommendation

the senate and one of whom

shall be appointed Each person

upon the recommendation as a director

the speaker of the assembly. ant to this paragraph ing areas:

appointed

pursu-

shall have expertise

in one or more of the follow-

7
8

(i) Individual

health

care coverage; care coverage;

(ii) Small employer

health

9
10 11 12 13 14 15 16 17 18

(iii) Health benefits

administration;

(iv) Health care finance;

(v) Public or private health health care delivery systems; and

(vi) Purchasing

plan coverage. shall take into consideration and appointed reflects pursuant the

(c) Recommendations expertise

and appointments

of other directors

recommended

to this of expe-

subdivision, rience.

so that the board composition

a diversity

(d) Recommendations speaker of

by the temporary

president

of the senate

and

the

the assembly

shall be made within

thirty

days of the effecof a

19
20 21 22 23 24 25 26

tive date of this article or within thirty days of the occurrence

vacancy. If a recommendation for an appointment shall be is not received to make

within that

such period appointment 4. The

of time, the governor without governor

authorized

a recommendation. shall appoint a chair of the board from among the

directors. 5. (al The terms of the directors, tors, shall be three years, provided, other than the that: ex officio direc-

however,

05/31/11

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 to

(i)

the

initial

terms of the directors

appointed

upon recommendation of the assembly

of the temporary

president

of the senate and the speaker

shall be for two years; and (ii) the initial term of one of the remaining directors shall be for

one year. (b) Vacancies occurring otherwise than by expiration of term of office

s-h-a-l-±----be ~___h_e__lffi-e-AFl-i_r_ea---t-e-r--m--------Hi--___t_h-e----mann_e_;; fill e original appointment. shall not receive any compensation

pr-G-V-id-e-d--f-G-x ----------------------

6. The directors as directors.

for their services

7. (a) Each member meet the

of the board of

shall have the responsibility this article, the federal to serve seeking

and duty

reguirements

act, and all the public care

applicable interest coverage

state and federal of the

laws and regulations

individuals the exchange.

and small businesses

health

through

(b) No member the exchange. 8.

of the board may be employed

or

otherwise

retained

by

Ca) The board may create

such committees and at

as the board the first

deems necesmeeting its members other in a

sary. At the first meeting each subseguent year,

of the board, board

the

shall elect

from among such

secretary

and a treasurer.

The board

also shall elect

offi-

cers as it_ shall deem necessary. powers (b) and duties The board, as are assigned

The officers

so elected

shall have such

by the by-laws thereof,

and this chapter. by eleclaw. the

and any committee with article

may hold meetings

tronic means
§ 3983.

consistent powers

seven of the public The exchange

officers shall

General powers:

of the exchange.

have

following

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1. to

10

12048-06-1

sue and be sued and to participate in actions and proceedings,

whether judicial, administrative, arbitrative or otherwise; 2. to have a corporate seal, and to alter such seal at pleasure, and affixed or impressed or

to use it by causing it or a facsimile to be reproduced in any other manner; 3. to purchase, receive, take by

grant, gift, devise, bequest or use

otherwise, lease, or otherwise acquire, own, hold, improve, employ,

and otherwise deal in and with, real or personal property, or any interest therein, wherever situated; 4. to purchase, take, receive, subscribe for, or otherwise acquire, sell, lend, lease, exchange, transfer, or

own, hold, vote, employ, otherwise dispose of,

mortgage, pledge, use and otherwise deal in and

with, bonds and other obligations, shares, or other securities or interests issued by others, whether engaged in similar or different business,

1'5 governmental, or other activities; 16 17 18 19 20 21 22 23 24 25 26 27 28 5. to sell, convey, lease, exchange, transfer or otherwise dispose of, or mortgage or pledge, or create a security interest in, all or its property, or any 6. to interest therein, wherever situated; any of

fix, compromise and collect rates, fees, and other charges for

the services rendered by it from the users of such services; 7. to make contracts, borrow money; 8. to invest and reinvest its funds, and take and hold real and of funds so loaned or give guarantees and incur liabilities, and

personal property as security for the payment invested; 9. to conduct the activities

of the exchange and have offices and jurisdiction within

exercise the powers granted by this article in any or without the United States;

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11

12048-06-1

10. to make and alter by-laws for its organization and management; 11. to make of and its alter rules and regulations as necessary for the this article, subject to the

fulfillment

purposes

under

provisions of the state administrative procedure act; 12. to hire employees, pursuant to section three thousand nine hundred ninety of this article; 13. to designate the depositories of its money; 14. to establish its fiscal year; and 15. to insure or otherwise to provide for the insurance of the risks as the

exchange's property or operations and against such other exchange may deem advisable; 16. to spend money

for any of its corporate purposes in accordance

with this article; and 17. to apply for, accept the award of, and spend any money.
§

available

grant

3984. Functions of the exchange.

The exchange shall:

1.

fa) make available qualified health plans to qualified individuals thou-

and qualified employers beginning on or before January first, two sand

fourteen, and shall not make available any health plan that is not

a qualified health plan; (b) make available qualified dental plans to qualified individuals and qualified employers, either separately or in conjunction with fied a quali-

health plan, if such plan provides pediatric dental Qenefits rneet-

ing the requirements of section 1302(b)(1)(J) of the federal act; 2. provide, in each area of this state, a choice of qualified health

plans at each of the levels of coverage contained in section l302(d) and (e) of the federal act;

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 in 3. assign

12

12048-06-1

a rating to each qualified health plan offered through the criteria developed by the secretary

exchange in accordance with the pursuant to section

1311(c)(3) of the federal act, and determine each

qualified health plan's level of coverage in accordance with regulations issued by the secretary pursuant to section 1302(d)(2)(A) of the federal act; 4. utilize a standardized format for presenting health benefit options the exchange, including the use of the uniform outline of coverage

established under section 2715 of the federal public health service act; 5. if the board deems it appropriate, standardize the benefits avail-

able through the exchange at each level of coverage specified in section 1302(d) of the federal act; 6. provide for enrollment periods pursuant to section 1311(c)(6) of

the federal act; 7. implement procedures for decertification of health the certification, recertification and

plans as qualified health plans, consistent section 1311(c)

with guidelines developed by the secretary pursuant to of the

federal act and section thirty-nine hundred eighty-five of this

article; 8. establish the minimum requirements an considered for participation in the insurer shall meet to be

exchange

and

the criteria for

selecting qualified health plans to be offered through the exchange that are in the best interests of qualified individuals and qualified employers, in addition to thOSe set forth in section thirty-nine hundred

eighty-five of this article; 9. require qualified health plans to offer those benefits determined benefits pursuant to section

by the secretary to be essential health 1302(b) of the federal act;

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 2S 26 27 28

13

12048-06-1

10. ensure that insurers offering health plans through the exchange do not charge an individual a fee or penalty for termination of coverage; 11. provide for the operation of a toll-free telephone hotline to

respond to requests for assistance; 12. maintain an internet website through which enrollees and prospec-

tive enrollees of qualified health plans may obtain standardized compar~ ative information on such plans; 13. establish and make available by electronic means a calculator to coverage after the application of any

determine the actual cost of premium tax credit under

section 36B of the Internal Revenue Code of of the federal

1986 and any cost-sharing reduction under section 1402 act, 14. establish a program under

which the exchange awards grants to section 1311(i) of

entities to serve as navigators in accordance with the federal act and regulations adopted thereunder;

15. if the board deems it appropriate, selectively contract for health care coverage offered to qualified individuals and qualified employers

through the exchange, and in doing so shall seek to contract with insurers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service; 16. determine what role licensed health insurance producers should

play in the exchange in accordance with the insurance law, 17. in accordance with section 1413 of the federal act, inform indi-

viduals of eligibility requirements for the medicaid program under title XIX of the social security act, the children's health insurance (CHIP) under title XXI of program

the social security act or any applicable

state or local public health insurance program and if, through screening of the application by the exchange, the exchange determines that such

05/31/11

14

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

individuals

are

eligible

for any such program,

enroll

such individuals

in such program; 18. pursuant attesting under is to section 1411 of the federal for purposes act, grant a certification responsibility penalty

that,

of the individual Revenue

section

SOCOA of the Internal the individual

Code of 1986, an requirement

individual or from the

exempt

from

responsibility

penalty

imposed by that section because: is no affordable gualified employer, health plan available through or the

(al there exchange

or the individual's meets

covering

the individual;

(bl the individual from the individual 19. transmit sury:

the requirements

for any other or penalty; States

such exemption

responsibility

requirement

to the secretary

of the united

department

of trea-

(al a list of the individuals ication under subdivision

to whom the exchange of this section,

granted

certifthe name

eighteen number

including

and taxpayer

identification

of each individual; number of each individual who

(b) the name and taxpayer was an employee premium

identification

of an employer

who was determined 36B of the

to be eligible Revenue

for the Code of

tax credit under

section

Internal

1986 because:
( i)

the employer

did not provide pursuant

minimum

essential

coverage

as deter-

mined by the secretary or (ii) mined the employer

to section

1311 (d) of the

federal

acti

provided pursuant under

the minimum to section

essential 1311(d~

coverage

as deteract,

by the secretary

of the

federal

but it was determined

section

36B(c)(2)(C)

of the Internal

Revenue

Code of 1986 to either be unaffordable the reguired minimum actuarial value;

to the employee and

or to not provide

05/31/11

15

12048-06-1

1 2

(c) the name and taxpayer

identification notifies

number

of: pursuant to section and

(i)

each

individual

who

the exchange

·'3 1411(b) (4) of the federal 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

act that he or she has changed coverage under

employers~

(ii) each individual

during

who ceases

a qualified

health plan

a plan year and the effective to each employer

date of that cessation; of the employer section who

20. provide described ceases

the name of each employee nineteen

in paragraph

(bl of subdivision

of this

coverage

under a qualified

health plan during

a plan year and the

effective 21.

date of the cessation; a small business health act options program ("SHOP") pursuant employers

operate

to section access

1311 of the federal

through and may: merge

which

qualified

coverage

for their employees,

(a) if the board deems with operations (bl permit employees regarding

it appropriate qualified

the operation

of such SHOP

individuals; a level of coverage so their the the in

qualified enroll

employers

to specify

may

in any qualified level of coverage a specific

health plan offered or, unless

through by

SHOP at the specified federal act, provide

prohibited

amount

or other payment

formulated

accordance plan; and

with the federal

act to be used as part of an employee

choice

(c) provide administrative 22. review the exchange, on whether

premium burdens

aggregation

and other related employers; within

services

to minimize

for qualified

the rate of premium and consider to continue

growth

the exchange

and

outside

the information limiting

in developing employer

recommendations status to small

qualified

employers; 23. enter into agreements and other state exchanges as necessary with federal and state agencies under this

to carry out its responsibilities

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 article, provided such

16 agreements any include

12048-06-1 adequate protections with to be shared and

respect to the confidentiality of

information

comply with all state and federal laws and regulations; 24. perform duties reguired by the secretary or the secretary of the eligibility

United States department of treasury related to determining for premium

tax credits, reduced cost-sharing, or individual responsi-

bility requirement exemptions; 25. meet financial integrity requirements under section federal act and this chapter, including: Ca) keeping an accurate accounting of all activities, receipts, and concern1313 of the

expenditures and annually submitting to the secretary a report ing

such accountings, with a copy of such report provided to the gover-

nor, the temporary president of the senate and the speaker of the assemblYi and (b) fully cooperating with any investigation conducted by tary pursuant to the secre-

the secretary's authority under section 18033 of the

federal act and allowing the secretary, in coordination with the inspector general of the United States department of health and human

services, to:
(i) investigate the affairs of the exchange;

(ii) examine the properties and records of the exchange; and (iii) require periodic reports in relation to the activities undertaken by the exchange; 26. Cal consult with the advisory committee established pursuant to

section thirty-nine hundred eighty-six of this article; and (b) consult with stakeholders relevant to carrying out the required under this article, including but not limited to: Ci) health care consumers who are enrollees in gualified health plansi activities

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 (ii)

17

12048-06-1

individuals and entities with experience in facilitating enroll-

ment in qualified health plans; (iii) uals; (iv) state medicaid offices; and (v) advocates for enrolling hard to reach populations; 27. submit information provided by exchange applicants tion in accordance with the reguirements for verificarepresentatives of small businesses and self-employed individ-

of section l411(c) of the

federal act; 28. establish rules and regulations, pursuant to subdivision eleven of section thirty-nine hundred eighty-three of this article, conflict with that do not

or prevent the application of regulations promulgated by

the secretary; and 29. determine eligibility, provide notices, and provide for appeal and opportunities

redetermination in accordance with the requirements of

sections 1411 and 1413 of the federal act.

§

3985. Special functions of

the

exchange

related

to

health

plan

certification

and qualified health plan oversight. a qualified health plan

1. The exchange may if the following

certify a health plan as requirements are met:

(al the insurer offering the health plan: (i) is licensed or certified and in good standing to offer health

insurance coverage in this state; (ii) offers at least one qualified health plan in each of the benefit

levels as the exchange may require to be offered by insurers participating in the exchange;

05/31/11

18

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

(iii)

has filed with and received rates and policy health

approval

from the superintendent

of

its premium

or contract

forms pursuant

to the insurance

law and the public

law; any cancellation thirty-nine fees or penalties hundred

(iv)

does

not charge

in violation
of this

of subdivision article; (v) and

ten of section

eighty-four

complies 1311(c)

with

the

regulations

developed

by the secretary requirements as

under the

section
exchange (b)

of the federal

act and such other

may establish; (i) provides the essential health and benefits includes packsuch except

the health plan:

age described additional

in section 1302(a) of the federal act

as the exchange may require

benefits

to be covered, essential plans

that the health plan shall not be required that duplicate the minimum benefits

to provide

benefits

of qualified least

dental one

if:
dental

(Al the .exchange has determined plan {B) health provide

that at

qualified and

is available
the plan,

to supplement

the health plan's disclosure

coverage;

insurer makes

prominent

at the time it offers that the plan does

the not

in a form approved

by the exchange, pediatric

the full range of essential plans providing

benefits,

and that qualibenefits not

fied dental covered

those benefits through

and other dental

by the plan are offered at least a of

the exchange, of coverage the plan as defined

(ii) provides section gualified al act, 1302(d)

bronze

level

in
as a

the federal

act, unless

is certified

catastrophic and shall coverage,

plan, as defined only be offered

in section to

1302(el

of the federeligible for

individuals

catastrophic

05/31/11

19

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 or

(iii)

has

cost-sharing

requirements, under

including section

deductibles, of the

which do federal

not exceed

the limits

established

1302(c)

act and any requirements (iv) complies 1311(c)

of the exchange; promulgated act, which network by the secretary include minimum pursuant standards comrnu-

with regulations of the federal

to section

in· the areas of marketing

practices, areas,

adequacy,

essential

nity providers
uniform quality

in underserved

accreditation,

quality

improvement, on

enrollment measures

forms and descriptions benefit

of coverage

and information

for health

plan performance; by the exchange, the provided of

(v) meets

standards

specified

and determined

that the standards federal

do not conflict

with or prevent

application

requirements; complies with the insurance law and issued the public health law

(vi)

requirements regulations prevent (vii)

applicable promulgated

to health pursuant

insurance thereto

in this state and any conflict with or

that do not

the application

of federal

requirements; for certification established

meets any additional

requirements and

by federal

or state law or regulation; determines is that

(c) the exchange through qualified the

making

the

health

plan

available and

exchange

in the interest

of qualified

individuals

employers

in this state. a health plan: plan is a fee-for-service price controls by the plan; exchange;

2. The exchange

shall not exclude

(a ) on the basis that the health (b ) through the imposition

of premium

(c) on the basis that the health prevent patients' deaths

plan provides

treatments

necessary

to are

in circumstances

the exchange

determines

inappropriate

or too costly.

OS/31/11

20

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

3. The exchange

shall reguire

each insurer plan to:

seeking

certification

of

health plan as a qualified (a) submit a justification exchange and the

health

for any premium prior

increase

or decrease

to the

superintendent

to implementation. on its internet

The insurer website. The

shall prominently exchange

post the information

shall take this information, provided to the

along with the information exchange by the superintendent when

and the under

recommendations section whether exchange.

1003 of the federal

act,

into

consideration plans shall

determining through to the the

to allow the insurer Such rate increases

to make health or decreases

available be

subject

prior approval (b}(i) secretary make

of the superintendent; available to the public and submit to the exchange, disclosure of: the

and the superintendent, policies

accurate

and timely

(Al

claims payment

and practices;

(B l periodic

financial

disclosures; and disenrollment; of claims that are denied;

(el data on enrollment

(D ) data on the number ( E) (F)

data on rating practices; information on cost-sharing and payments with respect to any out-

19
20 21 22 23 24 25 26 27 28 is

of-network (G)

coverage; on enrollee and participant rights under title I of

information act; and

the federal (E) other otherwise

information

as determined

appropriate

by

the

secretary

or

reguired

by the exchange; shall be provided 1311(e)(3)(B) in plain language, as that term

(ii) the information defined in section

of the federal

act, and in guidance secretary of

jointly labor;

issued and

thereunder

by the secretary

and the federal

05/31/11

21

.12048-06-1

1 2 3 4 5 6 7 8 9
10

(c) provide to individuals, in a timely manner upon the request of the individual, the amount of cost-sharing, including deductibles, copayor coverage

ments, and coinsurance, under the individual's health plan 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 other means for individuals

through an internet website and without access to the internet. 4.

The exchange shall not exempt any insurer seeking certification of or size of the insurer, from

a health plan, regardless of the type

11 12
13 14

licensing or solvency requirements under the insurance law or the public health law, and shall apply the criteria of this section in a manner insurers participating in the

that ensures a level playing field for exchange. 5. (al

15
16

The provisions of this article that apply to qualified health plans

plans also shall apply to the extent relevant to gualified dental except as

17 18 19
20 21

modified in accordance with the proviSions of paragraphs (b)

and (c) of this subdivision or otherwise required by the corporation. (b) The gualified dental plan shall be limited to dental and oral

health benefits, without substantially duplicating the benefits typically offered at by by a health benefit plans without dental coverage, and shall minimum, the the essential pediatric dental benefits of the

22 23
24

include, prescribed

secretary

pursuant to section 1302(h)(1)(J)

federal act, and such other dental benefits as the exchange or secretary may reguire. (c) Insurers may exchange in which jointly an offer a comprehensive plan through the

25
26

27
28

insurer

provides the dental benefits through a

gualified dental plan and an insurer provides the other benefits through

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

22 priced

12048-06-1 separately

a gualified health plan, provided that the plans are

and also are made available for purchase separately at the same price.
§

3986.

Advisory committee. exchange

1. There is hereby created the New York committee ("advisory committee"),

health

benefit

advisory

comprised of thirteen members appointed by the governor. (a) (i) Two members shall be appointed upon the-recommendation of the

temporary president of the senate. (ii) Two members shall be appointed upon speaker of the assembly. (iii) One member shall be appointed upon the recommendation of the the recommendation of the

minority leader of the senate. (iv) One member shall be appointed minority leader of the assembly. (b) The advisory committee shall be representative of the interests of health care consumers, small businesses, the medical community and upon the recommendation of the

insurers; and shall meet the following criteria: (i) five members shall be health insurance consumer advocates, including at least one small business consumer representative; (ii) four members shall be health care provider representatives; (iii) one member shall be a representative industry; (iv) one member shall be a New York licensed insurance producer; and (v) one member shall be a representative of a labor organization. tc) Appointments shall be made so that the membership of the advisory committee is representative of various areas of this state. (d) Recommendations by the temporary speaker of the assembly, the president of the senate, the of the health insurance

minority

leader of the senate and the the

minority leader of the assembly shall be made within thirty days of

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 effective date

23

12048-06-1

of this article or within thirty days of the occurrence appointment is not received

of a vacancy. If a recommendation for an within such period of

time, the governor shall be authorized to make

that appOintment without a recommendation. (el The board of directors shall select the chair of the advisory

committee from among the members of the advisory committee. (fl vacancies shall be filled in the same manner as original ments. (gl Members of the advisory committee shall serve without compenappoint-

sation. (hl As designated by the governor, three of the initial appointees

shall serve an initial term of three years, three shall serve an initial term of two years, and three shall serve an initial term of one year. years may and until their

Thereafter, members shall serve terms of three successors are appointed and qualify.

Members

serve up to two

consecutive terms. (il The advisory committee shall adopt rules for shall its governance and

meet at least once each guarter and at such other times as deter-

mined to be necessary. 2. The advisory committee shall provide advice tions to the board and make recommenda-

of directors with respect to the functions of the Such advice and recommendations

exchange as set forth in this article. shall

reflect consideration of regional variations to the extent deemed

appropriate by the committee. S 3987. Funding of the exchange. 1. The exchange shall be financially

self-sufficient by January first, two thousand fifteen. 2. The exchange shall conduct or cause to be conducted a study of, and shall report its findings and recommendations upon, the options to

05/31/11

24

12048-06-1

1 2 3 4 5 6

generate

funding

for the ongoing

operation

of the exchange, hundred

as provided of

for in subdivision this article. 3. The

seven of section

thirty-nine

eighty-eight

exchange

shall publish by the

on its internet exchange, and

website the

the fees and

any other payments

required

administrative

costs of the exchange, of monies 4.

to educate

consumers

on such costs and the amount

7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

lost to waste,

fraud and abuse. any funds intended for for the adminisstaff retreats, of to

The exchange

shall not utilize expenses excessive

trative

and operational giveaways, state

of the

exchange

promotional federal section or

executive

compensation,

or promotion pursuant

legislative

and regulatory act.

modifications

l4l1(cl

of the federal

5. No funds of the exchange or any special revenue

shall be transferred

to the

general other

fund than

fund or shall be used for any purpose in this article. and recommendations. 1. (al The

the purposes
§ 3988.

set forth

Studies,

findings

exchange

shall

conduct

or cause to be conducted

a study of, and shall make findhealth benefits of the federal identified act and of promulgated essential

ings and recommendations by the secretary

upon, the essential to section

pursuant under

l302(b)

the benefits thereunder health matters

required

the insurance by the

law or regulations secretary to be

that are not determined

benefits. including

Such study, findings but not limited health to:

and recommendations

shall address

(i) whether policies

the essential

benefits

required

to be

included

in

and contracts

sold through

the exchange

should be sold to simicoverage outside of the

larly situated exchange;

individuals

and groups purchasing

05/31/11

25

12048-06-1

1 2 3 4 S 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

(ii) lations health

whether

any

benefits thereunder

required that are

under the insurance not identified

law or reguas essential in polisitu-

promulgated benefits

by the secretary sold either and groups

should no longer the exchange

be required

cies or contracts ated individuals

through

or to similarly

outside

of the exchange; required under the insurance sold

(iii) the costs of extending law or regulations through (iv) promulgated and to

any benefits thereunder

to policies

and contracts

the exchange; mechanisms

finance

any

costs

pursuant

to

section reguired to poli-

1311(dl(3l(B)(ii) under the

of the federal

act of extending

any benefits thereunder

insurance

law or regulations

promulgated

cies and contracts (b) In making consider and

sold through and

the exchange. recommendations, the outside exchange shall

its findings

the individual approaches

and small group markets to prevent

of the exchange remain

consider with

marketplace

disruption,

consistent

the exchange

and avoid anti-selection. of its findings president and recommenda-

(c) The exchange tions speaker to the

shall submit a report the temporary

governor,

of the senate and the twelve. a study of, (il insurers all health purchasing

of the assembly

on or before

July first,

two thousand

2. (al The exchange

shall conduct

or cause to be conducted upon, whether

and shall make findings participating plans in the

and recommendations exchange

should be required or small

to offer groups

sold in the exchange outside

to individuals

coverage (ii)

of the exchange; and small group markets should be placed entirely

the individual

inside the exchange; (iii) the benefits standardized both

and in the individual and small group markets should be

inside and outside

the exchange.

05/31/11

26

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

(bl The exchange

shall submit

a report

of its findings of the

and recommendasenate and twelve. a study of, the state the

tions to the governor, speaker of the assembly

the temporary on or before

president

July first,

two thousand

3. (al The exchange and shall make

shall conduct and

or cause to be conducted

findings

recommendations

upon, whether

should

establish

a basic health plan program 1331 of the federal shall submit a report the temporary on or before shall conduct implementation market act.

identified

by the secretary

pursuant

to section

(bl The exchange

of its findings of the

and recommendasenate and twelve. a study of reinsurance mechthe the

tions to the governor, speaker 4. of the assembly

president

July first,

two thousand

(al The exchange and

or cause to be conducted of the transitional

the development program anisms federal for the

individual in accordance

and any other risk adjustment 1341, 1342 and 1343 of

developed act; and

with sections

(bl The exchange tions speaker to the

shall submit a report the temporary

of its findings president

and recommendaand the

governor,

of the senate

of the assembly

on or before

July first, two thousand or cause to be conducted upon, whether markets to

twelve. a study of, merge the

5. (al The exchange

shall conduct

and shall make findings individual

and recommendations insurance

and small group health

for rating purposes. and recommendaand the

(bl The exchange tions speaker to the

shall submit a report the temporary

of its findings president

governor,

of the senate

of the assembly

on or before

July first, two thousand or cause to be conducted upon, whether

twelve. a study of,

6. (al The exchange

shall conduct

and shall make findings

and recommendations from an average

to

increase

the size of small employers

of at least one but not more

05/31/11

27

12048-06-1

1 2 3 4 5

than fifty employees hundred employees

to an average

of at least one but not more than one first, two thousand sixteen; and

prior to January shall submit

(b) The exchange tions speaker to the

a report of its findings president

and recommenda-

governor,

the temporary

of the senate and the twelve. a study of, to generbut not

of the assembly

on or before

July first,

two thousand

7. Ca) The exchange

shall conduct

or cause to be conducted upon, the options

7 and shall make findings and recommendations

8 9 10 11 12 13 14 15 16 ate funding for the ongoing operation

of the exchange

including

limited

to assessments

upon insurers

and providers; of its findings of the and recornmendasenate and twelve. a study of, benefits under the are not the

(b) The exchange

shall submit a report the temporary on or before

tions to the governor, speaker of the assembly

president

July first, two thousand or cause to be conducted upon,

8. (al The exchange

shall conduct

and shall make findings identified public by the

and recommendations and of

the benchmark reguired that

secretary

the benefits

health

law or regulations

promulgated

thereunder benefits.

17
18 19 20 21 22 23 24 25 26 27 28

determined

by the secretary

to be benchmark

Such study, findbut not limited

ings and recommendations to: (il whether lations benefits fits

shall address

matters

including

any benefits

reguired that

under are

the public not

health

law or reguas benchmark benethe

promulgated

thereunder

identified

by the secretary to newly

should no longer be reguired medicaid-eligible

as covered inside

available

individuals

exchange; (ii) health the costs of extending any benefits reguired as under covered the public benefits

law or regulations to

promulgated

thereunder individuals

available and

newly medicaid-eligible

through

the exchange;

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

28

12048-06-1 act of

(iii) mechanisms to finance any costs pursuant to the federal extending any benefits reguired

under the public health law or regucontracts sold through

lations promulgated thereunder to policies and the exchange.

(b) The exchange shall submit a report of its findings and recommendations to the governor, the temporary president of the senate and the

speaker of the assembly on or before July first, two thousand twelve. 9. ra) The exchange shall make recommendations upon the impact of establishment and operation of the the

exchange on the healthy New York hundred twenty-six

program established pursuant to section forty-three of the insurance law

and the family health plus employer partnership sixty-nine-ff of

program established pursuant to section three hundred the social services law.

(b) The exchange shall notify the governor, the temporary president of the senate and the speaker of the assembly of its recommendations on or

before July first, two thousand twelve. 10. (al The exchange shall make recommendations upon what extent health savings accounts should be whether and to

offered through the

exchange. (h) The exchange shall notify the governor, the temporary president of the senate and the speaker of the assembly of its recommendations on before July first, two thousand twelve. 11. ra) The exchange shall conduct or cause to be conducted a study to allow or

of, and shall make findings and recommendations upon, whether large

employers to participate in the exchange beginning January first,

two thousand seventeen. (b) The eXChange shall submit a report of its findings and recommendations to the governor, the temporary president of the senate and the

05/31/11

29

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

speaker teen. ----12.

of the assembly

on or before

December

first,

two thousand

four-

Any of the studies

and reports

required

under

this section this

may be or

combined otherwise 13.

with other studies undertaken

and reports

required

under

section

by the exchange

to the extent

feasible express in

and timely. or implied, subdivisions authority; deemed to

The exchange

shall have no authority,

whether

to implement one through

any recommendation

on the issues set forth without further

eleven of this section that nothing

statutory shall be

provided,

however,

in this subdivision elsewhere

alter any powers

§

expressly

granted

in this article. 1. It is hereby of its

3989. Tax exemption

and tax contract

by the state.

determined corporate this

that the creation purposes

of the exchange

and the fulfillment

is in all respects

for the benefit

of the people of shall be

state and is a public purpose. as performing

Accordingly, governmental

the exchange function and

regarded

an essential

in the exerthe exchange levies not

cise of the powers shall

conferred

upon it by this article, special

not be required

to pay any fees, taxes,

ad valorem

or assessments limited property, or other under

of any kind, whether

state or local,

including

but

to fees, taxes, special franchise taxes, taxes,

ad valorem

levies or assessments transfer

on real taxes it or

sales taxes,

taxes, mortgage owned by

upon or with respect control

to any

property

its jurisdiction,

or supervision,

or upon

the uses therein further-

of, or upon or with respect ance of the powers

to its activities upon

or operations

conferred tolls,

it by this title, rates, charges,

or upon or with or

respect other 2.

to any fares, received

rentals,

fees, revenues

income

by the exchange. into agreements annually or with any county or to

The exchange

may pay, or may enter or sums

or municipality

to pay, a sum

otherwise

05/31/11

30

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

provide

other considerations located Officers

with respect

to real property

owned by the

corporation
§

wi thin such county and employees.

or municipal.ity. shall have the power staff of the exchange class of to as

3990.

1. The board

appoint

employees

to serve as senior managerial

necessary, service.

who shall be designated

to be in the exempt

civil of such

The board

shall also have the power

to fix the salaries

employees. 2. Any public officer or employee of a state department, without agency or and

commission without office,

may be transferred of any civil

to the exchange service

examination

loss

status or rights

to a comparable however, no

position

or employment

with the exchange~ the consent

provided,

such transfer ment, 3. agency The

may be made without or commission.

of the head of the depart-

salary or compensation

of any such officer

or employee,

after

such transfer,

shall be paid by the exchange. or employee transferred to the exchange pursuant to

4. Any officer this section,

who are members fund or system,

of or benefit

under any existing to have all rights,

pension privi-

or retirement leges, now

shall continue

obligations

and status with respect

to such fund or system as are of their employment by the by the

prescribed

by law, but during

the period

exchange, employer exchange.

all contributions on account

to such funds or systems or employees

to be paid

of such officers

shall be paid by the

5. A transferred

employee

shall remain

in the same collective successor shall,. service

bargainemployconsistlaw, be in

ing unit as was the case prior ees to the positions

to his or her transfer~ employees

held by such transferred of article fourteen

ent with the provisions included in the

of the civil

same unit as their predecessors.

Employees

serving

05/31/11 1 2 3 4 5 6 7 8
9

31

12048-06-1 collec-

positions in newly created titles shall be assigned to the same tive bargaining unit as the they would

have been assigned to were such of the exchange. Nothing

titles created prior to contained

establishment

in this article shall be construed (al to diminish the rights agreement or (b) to

of employees pursuant to a collective bargaining

affect existing law with respect to an application to the public employment relations board seeking a designation by the board that certain

persons are managerial or confidential.

§

3991. Limitation of liability; indemnification. seventeen and nineteen of

The provisions

of

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

sections

the public officers law shall be defined in sections

applicable to exchange employees, as such term is seventeen and nineteen

of the public officers law; provided, however,

that nothing contained within this section shall be deemed to permit the exchange.to extend the provisions of sections seventeen and nineteen the public officers law upon any independent contractor.
§

of

3992.

Contingency

for federal funding.

The implementation of the on sufficient federal

provisions of this article shall be

contingent

financial support to establish and implement the exchange.

§

3993. Construction.

Nothing in this article, and no action taken by

the exchange pursuant hereto, shall be construed to: 1. preempt or supersede the authority of the superintendent or the

commissioner; or 2. exempt insurers, insurance producers or gualified health plans from the public health law or the insurance law and thereunder. S 3. Subsection (al of section 3231 of the insurance law, as amended amended and a new subsection regulations promulgated

by chapter 661 of the laws of 1997, is (a-I) is added to read as follows:

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 (a) [No] Until January first,

32

12048-06-1

two thousand sixteen, no individual insurance policy covering

health insurance policy and no group health between two and fifty

employees or members of the group exclusive of hereinafter referred to as a small group,

spous~s and dependents, providing hospital

and/or medical benefits, including medicare supplesuch policy is

mental insurance, shall be issued in this state unless community rated and,

notwithstanding any other provisions of law, the imposition of a

underwriting of such policy involves no more than the

pre-existing condition limitation as permitted by this article. (a-I) Effective January first, two thousand sixteen, no individual

health insurance policy and no group health insurance policy covering an average of at least one but not members of the more than one hundred employees or

group exclusive of spouses and dependents, hereinafter and/or medical bene-

referred to as a small group, providing hospital

fits, including medicare supplemental insurance, shall be issued in this state unless such policy is community rated and, notwithstanding any such policy involves no

other provisions of law, the underwriting of more than the imposition of a

pre-existing condition limitation as

permitted by this article. ~ Any individual, and dependents of such individual, and any small employees or group members and dependents of

group, including all

employees or members, applying for individual health insurance coverage, including ance medicare supplemental coverage, or small group health insurmedicare supplemental the year insurance, must be

coverage, at all

including times

accepted

throughout

for any hospital and/or small groups

medical coverage offered by the insurer to individuals or in

this state. Once accepted for coverage, an individual or small group to claims experience. Termi-

cannot be terminated by the insurer due

05/31/11 1 2 3 4 S 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 nation of an individual

33

12048-06-1

or small group shall be based only on one or three thou-

more of the reasons set forth in subsection (g) of section

sand two hundred sixteen or subsection (p) of section three thousand two hundred twenty-one of this article. Group hospital and/or medical coverage, including medicare supplemental of insurance, fifty or obtained through an fewer employees or

out-of-state trust covering a group participating

persons who are residents of this state must be community

rated regardless of the situs of delivery of the policy. Notwithstanding any other provisions of law, the underwriting of such policy may involve no more than the imposition of a pre-existing condition limitation as

permitted by this article, and once accepted for coverage, an individual or small group cannot be terminated due to claims experience. Termionly on one or

nation of an individual or small group shall be based more of

the reasons set forth in subsection (p) of section three thoupurposes of this

sand two hundred twenty-one of this article. For the section, "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 policy or contract form of risks covered by that

without regard to age, sex, health status or

occupation.
§

4. The insurance law is amended by adding a new

section

3231-a

to

read as follows:
§

3231-a. Operation of the individual and small group health insurance in conjunction with the New York health benefit exchange. New York (a)

markets

For the purpose of this section, "exchange" means the benefit exchange established pursuant

health

to article ten-E of the public

authorities law.

05/31/11

34

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 by

(b) To ensure group health (1)

the effective markets

operation

of

the

individual

and

small

insurance

in conjunction

with the exchange: may direct participate to ensure

The superintendent, that is licensed

in consultation and operating

with the exchange, in this state to

an insurer

in the exchange the adequate (2) The

in one or more areas of the state of health plans may promulgate within

if necessary such region. to ensure

availability superintendent

regulations

that the set forth as

integrity in section added ty-two, prevent

of community

rating and open enrollment two hundred thirty-one

reguirements of this

three thousand

chapter, hundred

by chapter remain

five hundred

one of the laws of nineteen the establishment resulting of the plans

nineto

intact following disruption

exchange

marketplace

from health

sold through

the exchange

or directly

by insurers in

outside

of the exchange. with the exchange, shall

(3) The superintendent, develop vidual and implement market with and

consultation

the transitional any other

reinsurance

program

for the indideveloped act. as amended in

risk adjustment

mechanisms

accordance

sections

1341, 1342 and 1343 of the federal 4317 of the insurance is amended law,

§ 5. Subsection

(al of section of

chapter

661

the laws of 1997,

and a new subdivision

(a-I) is added

to read as follows: January first, two thousand sixteen, insurance no individual coverof are

(a) [No] Until health insurance

contract

and no group health or members

contract

ing between

two and fifty employees including agent hospital

of the group exclusive the premiums

spouses and dependents, paid by a remitting providing

contracts

for which hereinafter

for a group, and/or

referred

to as a Medisuch of

small group,

medical

benefits,

including unless

care supplemental contract

insurance,

shall be issued

in this state

is community

rated and, notwithstanding

any other provisions

05/31/11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

35

12048-06-1

law, the underwriting of such contract involves no more than the imposition cleo (a-I) Effective January first, two thousand sixteen, no individual coverof a pre-existing condition limitation as permitted by this arti-

health insurance contract and no group health insurance contract ing between an average

of at least one but not more than one hundred and dependents,

employees or members of the group exclusive of spouses hereinafter referred to as a

small group, providing hospital and/or insurance, shall be

medical benefits, including medicare supplemental issued in this state unless such contract

is community rated and, underwriting of such

notwithstanding any other provisions of law, the contract involves

no more than the imposition of a pre-existing condi-

tion limitation as permitted by this article. ~ Any individual, and dependents of such individual, and any small employees applying or group for members and dependents of

group, including all employees or

members,

individual or small group health

insurance coverage must be accepted at all times throughout the year for any hospital and/or medical coverage, insurance, including Medicare supplemental

offered by the corporation to individuals or small groups in individual or small group

this state. Once accepted for coverage, an cannot be terminated by

the insurer due to claims experience. Termion

nation of coverage for individuals or small groups may be based only one or more of the reasons set forth in subsection
(C)

of section four four thousand

thousand three hundred four or subsection (j) of section three hundred five

of this article. For the purposes of this section, the premium for

"community rated" means a rating methodology in which all persons

covered by a policy or contract form is the same, based on

05/31/11

36

12048-06-1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

the experience contract

of the entire pool of risks regard

covered

by

that

policy

or

form without The

to age, sex, health by adding

status or occupation. a new section 43l7-a to

6.

insurance

law is amended

read as follows: S 4317-a. markets For the Operation of the individual and small group health benefit means insurance (a)

in conjunction purpose exchange law. ensure the

with the New York health "exchange"

exchange.

of this section, established

the New York health of the public

benefit

pursuant

to article

ten-E

authorities (bl To

effective markets

operation

of the individual

and small

group health

insurance

in conjunction with

with the exchange: the exchange, may direct

(1) The superintendent, an insurer

in consultation

that is licensed

and operating

in this state to participate if necessary the exchange. to ensure reguirements that the to ensure

in the exchange the adeguate

in one or more areas of health

of the state plans within

availability

(2) The superintendent integrity in of community

may promulgate

regulations

rating and open enrollment three hundred seventeen

set forth remain market-

section

four thousand

of this article to prevent

intact following place disruption

the establishment resulting

of the exchange plans

from health

sold through

the exchange

or directly

by insurers

outside in

of the exchange. consultation with the exchange, shall

(3) The superintendent, develop vidual and implement market and

the transitional any other

reinsurance

program

for the indideveloped act. in

risk adjustment

mechanisms

accordance

with sections

1341, 1342 and 1343 of the federal 17 of the public officers

§ 7. Subdivision

1 of section

law is amended

by adding a new paragraph

(x) to read as follows:

05/31/11

37

12048-06-1

1 2 3 4

(x) For purposes directors, exchange law.

of this section, and employees

the term of the

"employee" New York

shall health

include benefit

officers

established

pursuant

to article

ten-E of the public

authorities

5
6

S 8. Subdivision
by adding

1 of section 19 of the public officers (j) to read as follows:

the term the "employee" York

law is amended

a new paragraph purposes officers

7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

(il

For

of this section, and employees of

shall

include benefit

directors, exchange law.

New

health

established

pursuant

to article

ten-E of the public

authorities

9.

If any provision or to violate regulation,

or application

of this act shall be held to be with any applicable federal

invalid, law or

or be inconsistent

that shall not affect

other provisions that

or applicaor

tions of this act which application; and to

can be given effect without that end, the provisions

provision

and applications

of this

act are severable.

§ 10. This

act shall take effect

immediately;

provided,

however,

that

until

such time as the members exchange

of the board of directors appointed pursuant

of the New York to section 3982

health benefit of the public

are initially

authorities

law, as added by section is convened, nothing

two of this act, and in this act shall of

the first meeting be deemed insurance services, available

of such board

to prevent or, after

the commissioner October

of health

or the superintendent

3, 2011, the superintendent the award of, and

of financial spending any of

from applying grant money

for, accepting pertaining consistent grant money

to the establishment with this act awarded prior or,

or operation at any

such exchange from accepting this act.

for purposes or spending

time, of

to the enactment