Section 2511. Child health insurance plan * 1

(a) The commissioner, in
  consultation with the superintendent, shall establish a program  to  the
  extent of funds available therefor through contractual arrangements with
  approved  organizations to provide covered health care services coverage
  for eligible children. The availability  of  coverage  for  primary  and
  preventive  health  care  services  and  inpatient  health care services
  coverage shall be continued pending approval of contractual arrangements
  that include covered health care services coverage and implementation of
  such coverage to the extent of funds available therefor.
    (b) Coverage for covered health care services shall not  be  effective
  until  such  time  as  contractual arrangements are executed pursuant to
  this section for such purposes and an eligible child is enrolled in  the
  program.
    * NB Effective until July 1, 2011
    * 1.  (a)  The  commissioner, in consultation with the superintendent,
  shall establish a program to the  extent  of  funds  available  therefor
  through  contractual arrangements with approved organizations to provide
  primary and preventive  health  care  services  coverage  and  inpatient
  health care services coverage for eligible children. The availability of
  coverage  for  primary  and  preventive  health  care  services shall be
  continued pending approval  of  contractual  arrangements  that  include
  inpatient  health  care  services  coverage  and  implementation of such
  coverage to the extent of funds available therefor.
    (b) Coverage for inpatient health care services shall not be effective
  until such time as contractual arrangements  are  executed  pursuant  to
  this  section for such purposes and an eligible child is enrolled in the
  program.
    * NB Effective July 1, 2011
    2. In  order  to  be  eligible  for  a  subsidy  payment  pursuant  to
  subdivision  three  of  this  section,  a child shall meet the following
  criteria:
    * (a) (i)  effective  January  first,  nineteen  hundred  ninety-nine,
  resides  in  a  household  having a net household income at or below one
  hundred ninety-two percent of the non-farm  federal  poverty  level  (as
  defined  and updated by the United States department of health and human
  services) or the gross equivalent of such net income; and
    (ii) effective July first, two thousand, resides in a household having
  a gross household income at or below two hundred fifty  percent  of  the
  non-farm  federal  poverty  level  (as defined and updated by the United
  States department of health and human services); and
    (iii) effective September first, two  thousand  eight,  resides  in  a
  household  having  a  gross  household  income  at or below four hundred
  percent of the non-farm federal poverty level (as defined and updated by
  the United States department of health and human services);
    * NB Effective until July 1, 2011
    * (a) resides in a household having a net household income at or below
  one hundred eighty-five percent of the non-farm  federal  poverty  level
  (as defined and annually revised by the federal office of management and
  budget) or the gross equivalent of such net income;
    * NB Effective July 1, 2011
    (b)  is  not  eligible for medical assistance, except that a child who
  becomes eligible for medical assistance after becoming an eligible child
  under this title, may be eligible for  a  subsidy  payment  pursuant  to
  subdivision  three of this section as medical assistance for a period up
  to three months after becoming eligible for medical assistance; and
    (c) does not have health care coverage under insurance, as defined  by
  the commissioner, in consultation with the superintendent. The applicant

  for  insurance  shall  attest  to  the  source and nature of the child's
  health care coverage under this paragraph, if any; and
    (d)  (i)  was  not  covered by a group health plan based upon a family
  member's employment, as defined by the commissioner in consultation with
  the superintendent of insurance, during the six month  period  prior  to
  the date of the application under this title; except in the case of:
    (A) loss of employment due to factors other than voluntary separation;
    (B)  death  of  the  family  member  which  results  in termination of
  coverage under a group health plan under which the child is covered;
    (C) change to a new employer that  does  not  provide  an  option  for
  comprehensive health benefits coverage;
    (D) change of residence so that no employer-based comprehensive health
  benefits coverage is available;
    (E)  discontinuation  of comprehensive health benefits coverage to all
  employees of the applicant's employer;
    (F) expiration of the coverage periods established  by  COBRA  or  the
  provisions  of  subsection  (m)  of  section  three thousand two hundred
  twenty-one, subsection (k) of section four thousand three  hundred  four
  and  subsection  (e)  of section four thousand three hundred five of the
  insurance law;
    (G) termination of  comprehensive  health  benefits  coverage  due  to
  long-term disability;
    (H)  cost  of  employment-based  health  insurance  is  more than five
  percent of the family's income;
    (I) a child applying for coverage under this title is pregnant; or
    (J) a child applying for coverage under this title is at or below  the
  age  of  five.  Implementation  of  this exception is subject to federal
  approval of the state's child health plan setting forth  such  exception
  and  submitted  in  accordance  with  Title  XXI  of  the federal social
  security act. If federal approval  is  not  granted  to  implement  this
  exception for children at or below the age of five, such exception shall
  be  implemented  at an alternate age specified by the federal government
  and included in the state's Title XXI child health plan.
    (ii) (A) The implementation of this paragraph for a child residing  in
  a  household  having  a  gross  household income at or below two hundred
  fifty percent of the non-farm federal  poverty  level  (as  defined  and
  updated  by  the  United States department of health and human services)
  shall take effect only upon the commissioner's  finding  that  insurance
  provided  under  this  title  is  substituting  for coverage under group
  health plans in excess of a percentage specified by the secretary of the
  federal department of health and human services. The commissioner  shall
  notify the legislature prior to implementation of this paragraph.
    (B)  The  implementation  of clauses (A), (B), (C), (D), (E), (F), (G)
  and (I) of subparagraph (i) of this paragraph for a child residing in  a
  household  having a gross household income between two hundred fifty-one
  and four hundred percent of  the  non-farm  federal  poverty  level  (as
  defined  and updated by the United States department of health and human
  services)  shall  take  effect  September  first,  two  thousand  eight;
  provided  however,  the  entirety  of subparagraph (i) of this paragraph
  shall take effect and be applied to such children on  the  date  federal
  financial   participation  becomes  available  for  such  population  in
  accordance  with  the  state's  Title  XXI  child   health   plan.   The
  commissioner shall monitor the number of children who are subject to the
  waiting period established pursuant to this clause.
    (e)  is  a  resident  of  New  York  state.  Such  residency  shall be
  demonstrated by adequate proof, as determined by the commissioner, of  a
  New  York state street address. If the child has no street address, such

  proof may include, but not  be  limited  to,  school  records  or  other
  documentation determined by the commissioner.
    (f)(i) In order to establish income eligibility under this subdivision
  at  initial  application,  a  household shall provide such documentation
  specified in subparagraph (iii) of  this  paragraph,  as  necessary  and
  sufficient  to  determine  a child's financial eligibility for a subsidy
  payment under this title. The commissioner may verify  the  accuracy  of
  such income information provided by the household by matching it against
  income  information contained in databases to which the commissioner has
  access,  including  the  state's  wage  reporting  system  pursuant   to
  subdivision five of section one hundred seventy-one-a of the tax law and
  by  means  of  an  income  verification  performed  by the department of
  taxation and finance pursuant to subdivision four of section one hundred
  seventy-one-b of the tax law.
    (ii) In order to establish income eligibility under  this  subdivision
  at   recertification,  a  household  shall  attest  to  all  information
  regarding the household's income that is  necessary  and  sufficient  to
  determine  a  child's  financial eligibility for a subsidy payment under
  this title and shall provide the social security numbers for each parent
  and legally responsible adult who is a member of the household and whose
  income is available to the child, subject to subparagraph  (v)  of  this
  paragraph.    The  commissioner  may  verify the accuracy of such income
  information provided by the household  by  matching  it  against  income
  information contained in databases to which the commissioner has access,
  including  the  state's  wage reporting system and by means of an income
  verification  performed  by  the  department  of  taxation  and  finance
  pursuant to subdivision four of section one hundred seventy-one-b of the
  tax  law. In the event that there is an inconsistency between the income
  information attested to by the household and any information obtained by
  the commissioner from other sources pursuant to this  subparagraph,  and
  such  inconsistency  is  material  to  the household's eligibility for a
  subsidy payment under this title, the  commissioner  shall  require  the
  approved  organization to obtain income documentation from the household
  as specified in subparagraph (iii) of this paragraph.
    (iii) Income documentation shall include, but not be limited  to,  one
  or  more  of the following for each parent and legally responsible adult
  who is a member of the household and whose income is  available  to  the
  child;
    (A) current annual income tax returns;
    (B) paycheck stubs;
    (C) written documentation of income from all employers; or
    (D)  other  documentation of income (earned or unearned) as determined
  by the commissioner, provided, however,  such  documentation  shall  set
  forth the source of such income.
    (iv)  In  the  event a household does not provide income documentation
  required by subparagraph (iii) of this paragraph within  two  months  of
  the  approved  organization's  request,  the approved organization shall
  disenroll the child at the end of  such  two  month  period.  Except  as
  provided  in  paragraph  (c)  of  subdivision  five-a  of  this section,
  approved organizations shall not be obligated to repay subsidy  payments
  made  by  the state on behalf of children enrolled during this two month
  period.
    (v) In the event  a  household  chooses  not  to  provide  the  social
  security  numbers  required by subparagraph (ii) of this paragraph, such
  household shall provide income documentation specified  in  subparagraph
  (iii)  of  this  paragraph  as  a  condition  of the child's enrollment.
  Nothing in this paragraph shall be construed as obligating  a  household
  to  provide  social  security  numbers of parents or legally responsible

  adults as a condition of a  child's  enrollment  or  eligibility  for  a
  subsidy payment under this title.
    (vi)  Any  income  verification response by the department of taxation
  and finance pursuant to subparagraphs (i) and  (ii)  of  this  paragraph
  shall  not  be  a  public  record  and  shall  not  be  released  by the
  commissioner, the department of taxation  and  finance  or  an  approved
  organization  except  pursuant  to this paragraph. Information disclosed
  pursuant to this paragraph shall be limited to information necessary for
  verification. Information so disclosed shall be kept confidential by the
  party receiving such information. Such  information  shall  be  expunged
  within  a  reasonable  time to be determined by the commissioner and the
  department of taxation and finance.
    * (g) (i) Notwithstanding any inconsistent provision  of  law  to  the
  contrary   and   subject   to  the  availability  of  federal  financial
  participation under title XIX of the  federal  social  security  act,  a
  child  under  the  age  of nineteen shall be presumed to be eligible for
  subsidy payments and temporarily enrolled for coverage under this title,
  once during a twelve month period, beginning on the  first  day  of  the
  enrollment  period  following  the  date  that  an approved organization
  determines, on the basis of preliminary information, that a child's  net
  household  income  does  not  exceed the income level specified in title
  eleven of article five of the social services law for children  eligible
  for  medical  assistance  based  on  such  child's  age.  The  temporary
  enrollment period shall continue  until  the  earlier  of  the  date  an
  eligibility determination is made pursuant to this title or title eleven
  of article five of the social services law, or two months after the date
  temporary  enrollment  begins;  provided however, a temporary enrollment
  period may be extended in the event an eligibility  determination  under
  this title or title eleven of article five of the social services law is
  not  made within such two month period through no fault of the applicant
  for insurance for medical assistance. The commissioner shall assure that
  children who  are  enrolled  pursuant  to  this  paragraph  receive  the
  appropriate  follow-up  for  a determination of eligibility for benefits
  under this title or title eleven of article five of the social  services
  law  prior  to  the  termination of the temporary enrollment period. The
  commissioner shall assure that children and their families are  informed
  of all available enrollment sites in accordance with subdivision nine of
  this section.
    (ii)   Effective   September  first,  two  thousand  seven,  temporary
  enrollment pursuant to subparagraph  (i)  of  this  paragraph  shall  be
  provided  only  to  children  who  apply for recertification of coverage
  under this title who appear to be eligible for medical assistance  under
  title eleven of article five of the social services law.
    * NB Expires July 1, 2011
    * (h)  The  commissioner may, in consultation with the superintendent,
  promulgate rules and regulations necessary to prevent fraud and abuse in
  eligibility determinations made by approved  organizations  pursuant  to
  this subdivision.
    * NB Expires July 1, 2011
    (j)  Where  an  application for recertification of coverage under this
  title contains insufficient information for  a  final  determination  of
  eligibility  for  continued coverage, a child shall be presumed eligible
  for a period not  to  exceed  the  earlier  of  two  months  beyond  the
  preceding  period  of  eligibility  or  the  date  upon  which  a  final
  determination  of  eligibility  is  made  based  on  the  submission  of
  additional  data.  In  the  event  such  additional  information  is not
  submitted within two months of the approved organization's request,  the
  approved organization shall disenroll the child following the expiration

  of  such  two  month  period.  Except  as  provided  in paragraph (c) of
  subdivision five-a of this section, approved organizations shall not  be
  obligated  to  repay  subsidy  payments  received  on behalf of children
  enrolled during this two month period.
    2-a. (a) An approved organization that has reasonable cause to believe
  that an applicant for insurance, parent or legally responsible adult has
  provided  false  income information may submit tax returns and any other
  available income information, including, if not  prohibited  by  federal
  law  for  purposes  of  income  verification,  social  security  account
  numbers, to the department as  may  be  necessary  to  determine  income
  eligibility.  The department shall promptly furnish to the department of
  taxation  and  finance,  pursuant  to  the  agreements   authorized   by
  subdivision  five  of  section one hundred seventy-one-a and subdivision
  four of section one hundred seventy-one-b of the  tax  law,  the  names,
  address  and  social  security  account  numbers,  if  available, of the
  parents and legally responsible adults who are members of the household,
  together with a request that the department  of  taxation  and  finance,
  pursuant to those agreements, promptly ascertain insofar as is possible,
  and  from  the most recent available data, whether the collective income
  reported by those individuals exceeds the income eligibility  level  for
  that  household,  as  determined  by  the  department in compliance with
  paragraph (a) of subdivision two of this  section.  The  department,  in
  consultation   with  the  department  of  taxation  and  finance,  shall
  establish  a  methodology  for  comparing  numerical   equivalents.   In
  ascertaining whether a household's income exceeds the income eligibility
  threshold  transmitted by the department, the department of taxation and
  finance shall also examine information available pursuant to section one
  hundred seventy-one-a of the tax law where any of the named  individuals
  have  failed  to  file  a  New York state income tax return for the most
  recent filing year or where there is an indication, from the  department
  or otherwise, that the individual's income may have changed. Reliance on
  such  section  one  hundred seventy-one-a information shall be specially
  indicated in the department of taxation  and  finance's  response.  This
  provision shall not be construed to authorize the department of taxation
  and  finance  to  disclose any figure on any personal income tax return.
  The department shall promptly inform the approved  organization  of  the
  response  from  the  department  of  taxation and finance. Submission of
  income information for verification shall not delay the  application  of
  any  other provision of this section to an applicant for insurance or an
  enrolled child.
    (b) Before an approved organization submits income information to  the
  department for verification with the department of taxation and finance,
  it shall:
    (i)  provide  the  applicant  for  insurance  with notification of its
  intent to seek such verification;
    (ii) notify the applicant for insurance  of  the  confidentiality  and
  expungement  provisions  contained in paragraph (c) of this subdivision;
  and
    (iii) provide the applicant for  insurance  with  the  opportunity  to
  review and modify the income information.
    (c)   Such   income  information  and  verification  response  by  the
  department of taxation and finance shall not  be  a  public  record  and
  shall  not be released by the department, the department of taxation and
  finance  or  the  approved  organization   except   pursuant   to   this
  subdivision.    Information  disclosed pursuant to this section shall be
  limited  to  information  necessary  for  verification.  Information  so
  disclosed  shall  be  kept  confidential  by  the  party  receiving such
  information.  Such  income  information  shall  be  expunged  within   a

  reasonable time to be determined by the department and the department of
  taxation and finance.
    3.  Subsidy  payments  shall be made, pursuant to subdivision eight of
  this section, to approved organizations for the purposes of  subsidizing
  the  entire  cost of coverage for eligible children meeting the criteria
  of subdivision two of this  section.  Notwithstanding  any  inconsistent
  provision  of  this subdivision, the total annual aggregate cost-sharing
  with respect to all eligible children in a  family  under  this  section
  shall not exceed amounts provided pursuant to applicable federal law. In
  order  to be eligible for a subsidy payment pursuant to this subdivision
  a premium payment shall be paid for an eligible child in accordance with
  the provisions of subdivision nine of section twenty-five hundred ten of
  this title. Nothing herein shall preclude  payment  of  the  premium  on
  behalf  of  an  eligible  child  on a monthly, quarterly, semi-annual or
  annual basis.
    * 4. Households shall report  to  the  approved  organization,  within
  thirty  days,  any  changes  in  New York state residency or health care
  coverage under insurance that may make a child  ineligible  for  subsidy
  payments  pursuant  to this section. Any individual who, with the intent
  to obtain benefits, willfully misstates income or residence to establish
  eligibility pursuant to subdivision two of  this  section  or  willfully
  fails  to  notify  an  approved organization of a change in residence or
  health care coverage pursuant  to  this  subdivision  shall  repay  such
  subsidy  to the commissioner. Individuals seeking to enroll children for
  coverage shall be informed that such willful misstatement or failure  to
  notify shall result in such liability.
    * NB Effective until July 1, 2011
    * 4.  Subsidy payments shall be made, pursuant to subdivision eight of
  this section, to approved organizations for the purposes of  subsidizing
  a  portion  of  the cost of coverage for optional primary and preventive
  health  services  for  eligible  children  meeting   the   criteria   of
  subdivision two of this section. The commissioner pursuant to regulation
  shall  determine  the costs to be borne by those individuals enrolled in
  optional primary and preventive health care services and shall take into
  account the household size and gross annual income.
    * NB Effective July 1, 2011
    * 4-a. Any  individual  who,  with  the  intent  to  obtain  benefits,
  willfully   misstates  income  or  residence  to  establish  eligibility
  pursuant to subdivision two of this section or willfully fails to notify
  an approved organization of an increase in income or change in residence
  pursuant to subdivision two of this section shall repay such subsidy  to
  the  commissioner.  Individuals  seeking to enroll children for coverage
  shall be informed that such willful misstatement or  failure  to  notify
  shall result in such liability.
    * NB Effective July 1, 2011
    * 5. Notwithstanding any inconsistent provisions of subdivision two of
  this section, an individual who meets the criteria of paragraphs (b) and
  (c) of subdivision two of this section but not the criteria of paragraph
  (a)  of  such  subdivision  may  be  enrolled  for  covered  health care
  services, provided however, that an approved organization shall  not  be
  eligible  to  receive  a  subsidy payment for providing coverage to such
  individuals.  The  cost  of  coverage  shall  be   determined   by   the
  commissioner,  in  consultation  with the superintendent and shall be no
  more than the cost of providing such coverage.
    * NB Effective until July 1, 2011
    * 5. Notwithstanding any inconsistent provisions of subdivision two of
  this section, an individual who meets the criteria of paragraphs (b) and
  (c) but not the criteria of paragraph (a) of  such  subdivision  may  be

  enrolled  for  primary  and preventive health care services, or optional
  primary and preventive health care services, and inpatient  health  care
  services,  provided  however, that an approved organization shall not be
  eligible  to  receive  a  subsidy payment for providing coverage to such
  individuals.  The  cost  of  coverage  shall  be   determined   by   the
  commissioner,  in  consultation  with the superintendent and shall be no
  more than the cost of providing such coverage.
    * NB Effective July 1, 2011
    5-a.  Obligations  of  approved   organizations.   (a)   An   approved
  organization  shall  have  the  obligation  to  review  all  information
  provided pursuant to subdivision two  of  this  section  and  shall  not
  certify  or  recertify  a child as eligible for a subsidy payment unless
  the child meets the eligibility criteria.
    (b) An approved organization shall  promptly  review  all  information
  relating  to  a  potential  change  in  eligibility based on information
  provided pursuant to subdivision four of this section. Within  at  least
  thirty days after receipt of such information, the approved organization
  shall  make  a  determination  whether the child is still eligible for a
  subsidy payment and shall notify the household and the  commissioner  if
  it determines the child is not eligible for a subsidy payment.
    (c)  Any approved organization which engages in a pattern and practice
  of enrolling or recertifying children who  are  ineligible  pursuant  to
  subdivision  two  of this section, as determined by the commissioner, in
  consultation with the superintendent, shall be  required  to  repay  all
  subsidy  payments  received  on account of ineligible children. Improper
  enrollment based upon a  good  faith  reliance  on  documentation  which
  appears accurate on its face shall not constitute a pattern or practice.
  Any  such  approved  organization  may  also  be  removed as an approved
  organization, provided however, that eligible children shall continue to
  receive services until such time as  the  orderly  transition  to  other
  approved organizations can be effected.
    6.  * The commissioner shall, in consultation with the superintendent,
  establish  guidelines  for  the  submission  of  proposals  by  eligible
  organizations for the purposes of providing covered health care services
  coverage  to  eligible  children  including,  but  not  limited  to, the
  following components:
    * NB Effective until July 1, 2011
    * The commissioner shall, in  consultation  with  the  superintendent,
  establish  guidelines  for  the  submission  of  proposals  by  eligible
  organizations for the  purposes  of  providing  primary  and  preventive
  health  care  services  coverage  and  inpatient  health  care  services
  coverage to  eligible  children  including,  but  not  limited  to,  the
  following components:
    * NB Effective July 1, 2011
    (a)  standards  for  individual  enrollment  including  mechanisms for
  presumptive eligibility and annual recertification;
    (b) standards for provider enrollment;
    * (c) standards for scope of covered health care service benefits;
    * NB Effective until July 1, 2011
    * (c) standards for  scope  of  primary  and  preventive  health  care
  service benefits and inpatient health care services benefits;
    * NB Effective July 1, 2011
    (d) standards for health care provider payment methodologies, provided
  however,  that  levels  and  methods of payment shall be consistent with
  those provided under similar insurance plans;
    (e) standards for appropriate utilization  review,  quality  assurance
  and case management mechanisms; and
    (f) such other criteria which may be deemed necessary.

    6-a.  The  commissioner,  in consultation with the superintendent, may
  establish a program for cards issued  to  eligible  children  which  can
  store  or  access  information electronically, including the identity of
  the  child  and  such  other  medical  data  and  information   as   the
  commissioner, in consultation with the superintendent, may prescribe.
    7. (a) A proposal submitted by an eligible organization shall meet the
  following criteria:
    (i)  designate  the  geographic  area to be served by the program, and
  estimate the number of eligible participants and actual participants  in
  such designated area;
    * (ii)  assure  access  to  and  delivery of high quality, appropriate
  covered health care services and, when applicable, include a network  of
  health   care   providers   in  sufficient  numbers  and  geographically
  accessible to service program participants;
    * NB Effective until July 1, 2011
    * (ii) assure access to and  delivery  of  high  quality,  appropriate
  primary  and  preventive  health care services and inpatient health care
  services  and,  when  applicable,  include  a  network  of  health  care
  providers in sufficient numbers and geographically accessible to service
  program participants;
    * NB Effective July 1, 2011
    (iii)   describe   the   procedures   for  marketing  and  determining
  eligibility for the health care coverage plan in the  program  location,
  including  the  designation  of  other  entities  which may perform such
  functions under contract with the organization;
    (iv) describe proposed health care provider payment methodologies;
    (v) describe in detail the  estimated  expenses,  including  personnel
  costs  and other types of administrative expenses which will be incurred
  in the development and implementation of the program;
    (vi) describe the  quality  assurance,  utilization  review  and  case
  management mechanisms to be implemented;
    (vii)  demonstrate  the  applicant's ability to meet the data analysis
  and reporting requirements of the program;
    * (viii) describe the benefit package to be offered by the program and
  the cost of such benefit package;
    * NB Effective until July 1, 2011
    * (viii) describe the benefit package including, optional primary  and
  preventive  health  care  services, to be offered by the program and the
  cost of such benefit package;
    * NB Effective July 1, 2011
    (ix) describe the provisions for arranging for or offering  conversion
  coverage in the event of termination of coverage under this title;
    (x) demonstrate financial feasibility of the program;
    (xi)  describe  the  premium, copayments and deductibles to be paid by
  program participants who are ineligible for subsidy payments; and
    (xii) include such other  information  as  the  commissioner  and  the
  superintendent may deem appropriate.
    (b)  The  commissioner, in consultation with the superintendent, shall
  make  a  determination  whether  to  approve,  disapprove  or  recommend
  modification  of the proposal. In order for a proposal to be approved by
  the  commissioner,  the  proposal  must  also   be   approved   by   the
  superintendent  with  respect  to the provisions of subparagraphs (viii)
  through (xii) of paragraph (a) of this subdivision.
    (c) The commissioner, in consultation with the  superintendent,  shall
  ensure,  to  the  extent  possible,  that  child  health  insurance plan
  coverage is available in all  geographic  areas.  The  commissioner  may
  approve  more  than  one approved organization to serve all or part of a
  geographic area.

    7-a. (a) Notwithstanding any inconsistent provisions  of  subdivisions
  one  and  three  of section two thousand five hundred ten of this title,
  subdivisions six and seven of this section, subject to paragraph (b)  of
  this  subdivision,  and  section  one  hundred  sixty-three of the state
  finance  law,  the commissioner may contract with organizations approved
  under section three hundred sixty-four-j of  the  social  services  law,
  without  a  competitive  bid or request for proposal process, to provide
  covered health care services coverage for eligible children pursuant  to
  this title.
    (b)  In  order  to  be  approved  pursuant  to  this  subdivision,  an
  organization shall meet the criteria set forth in subdivision  seven  of
  this  section  and  shall  comply  with  standards  established  by  the
  commissioner, in  consultation  with  the  superintendent,  pursuant  to
  subdivision six of this section.
    (c)  Organizations  approved pursuant to this subdivision shall comply
  with  the  requirements  of  this  title  and   contractual   provisions
  established thereunder, title XXI of the federal social security act and
  any  implementing federal regulations, and requirements set forth in the
  state child health plan established pursuant to title XXI of the federal
  social security act.
    (d) Notwithstanding any inconsistent provision of section one  hundred
  twelve  or  one  hundred  sixty-three  of  the state finance law, at the
  discretion of the commissioner, without a competitive bid or request for
  proposal process, contractual arrangements with approved  organizations,
  as defined in subdivision two of section twenty-five hundred ten of this
  article,  in  effect in two thousand seven may be extended to any period
  on and after July first, two thousand seven to provide an  uninterrupted
  continuation of services and may be amended as deemed necessary.
    8.  The  commissioner  shall  determine  the  amount  of  funds  to be
  allocated to an approved organization  for  the  purposes  described  in
  subdivision one of this section within such funds which may be available
  for  the purposes of this article. (a) Subsidy payments made to approved
  organizations on and after April first, two thousand five through  March
  thirty-first,  two  thousand  six, shall be at amounts approved prior to
  April first, two thousand five. Applications for  increases  to  subsidy
  payments submitted by approved organizations to the superintendent on or
  after  January  first,  two  thousand  five, shall not be considered for
  approval until after March thirty-first, two thousand six. (b)  Further,
  subsidy  payments  made  to  approved  organizations  on and after April
  first, two thousand  seven  through  March  thirty-first,  two  thousand
  eight,  shall  be at amounts approved prior to April first, two thousand
  seven. Applications for  increases  to  subsidy  payments  submitted  by
  approved  organizations to the superintendent on or after January first,
  two thousand seven, shall not be considered  for  approval  until  after
  March  thirty-first, two thousand eight. (c) Nothing in this subdivision
  shall prohibit decreases in subsidy payments in accordance with relevant
  contract provisions.
    (d)(i) Effective April first, two thousand nine, payment for marketing
  and facilitated enrollment activities set forth in subdivision  nine  of
  this   section  and  included  in  subsidy  payments  made  to  approved
  organizations providing such services pursuant to a  contract  with  the
  state  shall  be  limited  to  an  amount  determined  annually  by  the
  commissioner.
    (ii) Such subsidy payments shall be adjusted by  the  commissioner  to
  remove  any  costs  of  approved  organizations  in excess of the amount
  determined in accordance with subparagraph (i) of this  paragraph  based
  on cost reports submitted to the department by approved organizations.

    * 9. (a) The commissioner shall develop and implement locally-tailored
  public   education,   outreach  and  facilitated  enrollment  strategies
  targeted to children who may be eligible for benefits under  this  title
  or  title  eleven  of  article  five of the social services law, and may
  contract  with  community  based organizations including but not limited
  to, child advocacy organizations, providers, school-based health centers
  and local government. In  awarding  contracts,  the  commissioner  shall
  consider  the  extent  to  which  such  organizations,  or coalitions of
  organizations, are able to  target  efforts  effectively  in  geographic
  regions  of  the  state  where the proportion of children enrolled under
  this title and title eleven of article five of the social  services  law
  is  lower  than  other  geographic  regions  of  the state. In approving
  entities to undertake activities pursuant to this subdivision, within  a
  defined  geographic  region,  the  commissioner  shall make a good faith
  effort to assure that a coalition is broadly inclusive of  organizations
  able to target effectively children who may be eligible under this title
  and title eleven of article five of the social services law.
    (b) Outreach strategies shall include, but are not limited to:
    (i) public education;
    (ii) dissemination of outreach materials regarding the availability of
  benefits  available under this title and title eleven of article five of
  the social services law, so long as such materials have been approved by
  the commissioner prior to distribution;
    (iii) recruitment of children who may be eligible under this title  or
  title  eleven  of article five of the social services law, including the
  distribution of a  common  application  form  for  services  under  such
  titles;
    (iv) outstationing of persons who are authorized to provide assistance
  to  families in completing the enrollment application process under this
  title and title eleven of article  five  of  the  social  services  law,
  including  the  conduct of personal interviews pursuant to section three
  hundred sixty-six-a of the social services law and  personal  interviews
  required  upon recertification under such section of the social services
  law, in locations, such as community settings, which are  geographically
  accessible to large numbers of children who may be eligible for benefits
  under  such  titles, and at times, including evenings and weekends, when
  large numbers of children who may be eligible for  benefits  under  such
  titles  are likely to be encountered. Persons outstationed in accordance
  with this subparagraph shall be authorized  to  make  determinations  of
  presumptive  eligibility in accordance with paragraph (g) of subdivision
  two of section two thousand five hundred and eleven of this title; and
    (v) notice by local social services districts  to  medical  assistance
  applicants  of  the  availability  of  benefits  under  paragraph (g) of
  subdivision two of section two thousand five hundred and eleven of  this
  title.
    (c) The commissioner shall assure that persons authorized to determine
  eligibility  under  title  eleven of article five of the social services
  law are placed in selected community settings.
    (d) Subject to the availability of funds therefor, training  shall  be
  provided   for   outstationed   persons   and   employees   of  approved
  organizations to enable them to disseminate information, facilitate  the
  completion  of  the  application  process  under  this  subdivision, and
  conduct  personal  interviews  required   by   section   three   hundred
  sixty-six-a  of the social services law and personal interviews required
  upon recertification under such section of the social services law.
    (e)  The  commissioner  shall  assure  that  outreach  activities  are
  coordinated  with  all  approved  organizations,  enrollment brokers and
  other relevant entities under this title and  title  eleven  of  article

  five  of  the  social  services law. The commissioner shall periodically
  monitor activities of these entities to  facilitate  the  completion  of
  applications  for  services and other activities under this subdivision.
  Such  monitoring  may  include,  but not be limited to, unannounced site
  visits. As part of the commissioner's assurance of coordinated  outreach
  activities, contracts with outreach organizations under this subdivision
  shall   include   enrollment  procedures  for  inquiring  into  existing
  relationships with health care providers and  procedures  for  providing
  information  about how such relationships may be maintained with respect
  to health care coverage under this  title  and  under  title  eleven  of
  article five of the social services law.
    (f)  Prior  to  entering  into  a contract under this subdivision, the
  commissioner  shall  require  that  potential   outreach   organizations
  disclose the nature of any contractual, financial, fiduciary or advisory
  relationships  they  have  with  any  approved  organizations  providing
  covered health care services,  and  with  the  department.  Applications
  submitted by organizations which fail to disclose any such relationships
  shall be eliminated from consideration for this program.
    (g) The commissioner is authorized to submit one or more amendments to
  the  appropriate  cost  allocation  plan  to enable the state to receive
  federal financial participation under title XIX and  title  XXI  of  the
  federal   social   security   act,  and  is  authorized  to  modify  the
  administration of this program in order to obtain the maximum amount  of
  federal financial participation for its components.
    (h)   Regardless  of  the  availability  of  funding  for  contractual
  arrangements, upon application the commissioner  may  permit  additional
  community-based  organizations  and  qualified  health care providers to
  perform education,  outreach  and  facilitated  enrollment  services  in
  accordance with this subdivision.
    (i)  The  provisions  of this subdivision shall be implemented only to
  the extent such  provisions  are  not  inconsistent  with  federal  law,
  regulation and administrative guidance.
    * NB Effective until July 1, 2011
    * 9.  The  commissioner  shall,  within  amounts  available  therefor,
  contract with community-based  and  other  marketing  organizations  for
  purposes  of  public  education,  outreach,  and recruitment of eligible
  children, including the distribution  of  applications  and  information
  regarding enrollment. In awarding such contracts, the commissioner shall
  consider  the  marketing,  outreach  and recruitment efforts of approved
  organizations, and the extent to which such organizations  are  able  to
  effectively target efforts in geographic regions where the proportion of
  eligible  children  enrolled  under  this  title are lower than in other
  geographic regions of the  state.  Community-based  organizations  shall
  include,   but   not   be   limited   to:  day  care  centers,  schools,
  community-based diagnostic and treatment centers, and hospitals.
    * NB Effective July 1, 2011
    10. Notwithstanding any other law or agreement to  the  contrary,  and
  except  in the case of a child or children who also becomes eligible for
  medical assistance,  benefits  under  this  title  shall  be  considered
  secondary  to any other plan of insurance or benefit program, except the
  physically handicapped children's program  and  the  early  intervention
  program, under which an eligible child may have coverage.
    11.  (a)  An  approved  organization shall submit required reports and
  information to the commissioner in such form  and  at  times,  at  least
  annually,  as  may  be  required  by  the  commissioner and specified in
  contracts and official department of health administrative guidance,  in
  order  to evaluate the operations and results of the program and quality
  of  care  being  provided  by  such  organizations.  Such  reports   and

  information shall include, but not be limited to, enrollee demographics,
  program  utilization  and  expense,  patient  care  outcomes and patient
  specific medical information, including encounter data maintained by  an
  approved  organization  for purposes of quality assurance and oversight.
  Any information or data collected pursuant to this  paragraph  shall  be
  kept  confidential  in  accordance  with Title XXI of the federal social
  security act or any other applicable state or federal law.
    (b) In the event an approved organization fails to submit any required
  report  and  information,  as  specified  in  contracts   and   official
  department  of health administrative guidance, on or before the due date
  specified by the commissioner, the commissioner may reduce the  approved
  organization's  subsidy  payments  by  up to a total of two percent each
  month for a period beginning on the first  day  of  the  calendar  month
  following  the  original due date of the required report and information
  and continuing until the last day of the calendar  month  in  which  the
  required  report  and  information  are  submitted; provided however, an
  approved organization shall not be subject to the  percentage  reduction
  under  the  following  conditions: (i) for any new report for which such
  organization did not have reasonable notice  which  shall  be  at  least
  sixty   days   notice   of   its   requirement,   data   and  submission
  specifications,  and  due  date  by  certified  mail  to  the   approved
  organization's  chief  financial officer; or (ii) for any report, upon a
  finding by the commissioner that such report  was  not  submitted  on  a
  timely  basis  for good cause, which may include, but not be limited to,
  additional time required to modify or add to computer data systems.
    12. The commissioner shall, in consultation with  the  superintendent,
  establish  procedures to coordinate the child health insurance plan with
  the medical assistance program, including but not limited to, procedures
  to maximize enrollment of eligible  children  under  those  programs  by
  identification  and  transfer of children who are eligible or who become
  eligible to receive medical  assistance  and  procedures  to  facilitate
  changes  in  enrollment  status  for  children  who  are  ineligible for
  subsidies under this section and for children who are no longer eligible
  for medical assistance in order to facilitate and ensure  continuity  of
  coverage.  The  commissioner  shall  review,  on  an  annual  basis, the
  eligibility verification  and  recertification  procedures  of  approved
  organizations  under  this title to insure the appropriate enrollment of
  children. Such review shall include, but not be limited to, an audit  of
  a  statistically  representative sample of cases from among all approved
  organizations. In the event such review and audit reveals cases which do
  not meet the  eligibility  criteria  for  coverage  set  forth  in  this
  section,   that   information   shall   be  forwarded  to  the  approved
  organization and the commissioner for appropriate action.
    12-a. The commissioner shall establish procedures  to  audit  approved
  organizations  for  compliance  with  the  requirements  of  this title,
  including the  requirements  of  subdivision  twelve  of  this  section,
  contractual  provisions  established  thereunder  and advisory memoranda
  issued by the commissioner, title XXI of the federal social security act
  and any implementing federal regulations, and requirements set forth  in
  the  state  child  health  plan established pursuant to title XXI of the
  federal social security act. Approved organizations  shall  comply  with
  such  procedures  and  make available any data necessary to perform such
  audits. Audit procedures shall include,  but  not  be  limited  to,  the
  following:
    (a)  standards  and procedures for a preliminary audit to be conducted
  on no more than an annual basis;

    (b)  standards  and  procedures  for  the  submission  of  a  plan  of
  correction  by  an approved organization, including time periods allowed
  to implement such plan of correction;
    (c)  standards  and  procedures  for a second audit, including an exit
  conference which provides an approved organization  the  opportunity  to
  rebut  the  composition  of  the audit sample as representative prior to
  recovery of subsidy payments and the imposition of penalties;
    (d) standards and procedures for recovery of subsidy payments made for
  ineligible children, which, notwithstanding any inconsistent  provisions
  of  this  title,  may  include recoveries based on extrapolated findings
  from a statistically representative  sample  of  cases  which  shall  be
  actuarially based and consistent with accepted auditing standards; and
    (e)  standards  and  procedures  for  the  imposition of penalties for
  substantial noncompliance, which may include, but  not  be  limited  to,
  financial penalties in addition to penalties set forth in section twelve
  of  this  chapter  and  consistent with applicable federal standards, as
  specified in contracts, and contract termination.
    13. On or before  January  first,  nineteen  hundred  ninety-two,  the
  commissioner  shall  report  to  the governor and the legislature on the
  implementation of the program of  primary  and  preventive  health  care
  services  coverage  established  pursuant  to  subdivision  one  of this
  section. Such report shall include, but not  be  limited  to:  a  status
  report  on  implementation  of  the  program  including  the  number  of
  individuals enrolled profiled by age and  geographic  location  and  the
  number and location of contractual arrangements entered into; the impact
  of  such  program  on  access  to  primary  and  preventive  health care
  services; the effect, expenditures and activities of the community-based
  outreach program; the number of children for  whom  an  application  for
  insurance coverage has been made and enrollees who were determined to be
  ineligible  and  the  reasons  therefor;  and, such other matters as the
  commissioner deems appropriate. The commissioner shall  report  annually
  thereafter  on  the  status  of  such  program, and on and after January
  first, nineteen hundred ninety-seven  including  inpatient  health  care
  services, including any recommendations for change or other modification
  in such program.
    14.  The  commissioner, in consultation with the superintendent, shall
  enter  into  agreements  with  one  or  more   persons,   not-for-profit
  corporations,  or  other  organizations,  other  than  a state employee,
  official or agency, for the performance of a comprehensive evaluation of
  the implementation and  effectiveness  of  the  child  health  insurance
  program.   Notwithstanding   any  inconsistent  provision  of  law,  the
  commissioner may allocate and distribute from funds otherwise  available
  for distribution for purposes of this title an amount not to exceed five
  hundred   thousand  dollars  for  the  costs  of  such  evaluation.  The
  evaluation shall include, but not be limited to:
    (a) the overall effect of the child health insurance program on access
  to, utilization and  quality  of  primary  and  preventive  health  care
  services,   including,   but   not   limited  to,  patterns  of  service
  utilization, geographic  availability  of  service  providers,  possible
  reductions  in  uncompensated  care  as  a  result  of  the program, and
  enrollee satisfaction with program administration, services and quality;
    (b) the impact of the child health insurance  program  on  the  health
  status  of  program  participants,  including  the comparative impact on
  families that have a child enrolled in the program  and  other  children
  that are not eligible and do not have coverage;
    (c) the effect of the child health insurance program on emergency room
  utilization,  including  the  effectiveness  of preventing inappropriate
  utilization;

    (d)  the  geographic  accessibility  of  the  child  health  insurance
  program,   including  the  availability  and  accessibility  of  service
  providers, premium levels and premium increases;
    (e)  the  effect  of  community-based and statewide outreach education
  efforts;
    (f) the results of a statistically valid sampling of  cases  verifying
  certification  and  recertification  of eligibility for subsidy payments
  under this title including  but  not  limited  to  data  on  failure  by
  approved organizations to adequately verify enrollee eligibility;
    (g)  any recommendations for programmatic changes to improve the child
  health insurance  program  based  on  program  evaluation  and  enrollee
  satisfaction data; and
    (h)  a  cost  and  patient  outcome  comparison of indemnity plans and
  managed care plans offered under this program.
    A preliminary evaluation shall be submitted to the  governor  and  the
  legislature  by  April first, nineteen hundred ninety-five and a further
  evaluation  shall  be  submitted  by  January  first,  nineteen  hundred
  ninety-six.
    14-a.  The commissioner shall enter into an agreement with one or more
  persons, not-for-profit corporations, or other organizations, other than
  a  state  employee,  official  or  agency,  for  comprehensive  research
  concerning  the  health care coverage of children in New York state. The
  organization conducting the research shall, at least annually,  issue  a
  report of its findings to the governor and the legislature. The research
  shall include, but not be limited to:
    (a) a survey of the uninsured in the state;
    (b) on-going comprehensive studies of the characteristics of uninsured
  children  and their families, including demographic characteristics, and
  reasons such children and families are uninsured;
    (c) the collection  and  dissemination  of  data  and  other  relevant
  information  relating  to the health care coverage of children and their
  families; and
    (d) a review of such factors relating to the  uninsured  in  New  York
  state  as  the  commissioner,  in  consultation with the superintendent,
  shall require.
    15. Notwithstanding any inconsistent provision of section one  hundred
  twelve  or one hundred sixty-three of the state finance law or any other
  law, at the discretion of the commissioner without a competitive bid  or
  request for proposal process:
    (a)  contractual  arrangements  with approved organizations to provide
  primary and  preventive  health  care  services  coverage  for  eligible
  children,  or  with  organizations  for  purposes  of  public education,
  outreach and recruitment of eligible children,  in  effect  in  nineteen
  hundred  ninety-three  may  be  extended  to  provide  for  primary  and
  preventive health care services coverage for eligible children or public
  education, outreach and recruitment of  eligible  children  in  nineteen
  hundred   ninety-four   and   nineteen  hundred  ninety-five  and  those
  contractual arrangements with approved organizations to provide  primary
  and  preventive  health  care services coverage for eligible children in
  effect for nineteen hundred ninety-five may  be  extended  through  June
  thirtieth,  nineteen  hundred  ninety-six  to  provide  an uninterrupted
  continuation of services and additional time for program evaluation  and
  may  be  amended  as  may  be  necessary,  provided,  however,  that the
  commissioner shall periodically review the process of ensuring  adequate
  participation of approved organizations under this section; and
    (b)  contractual  arrangements  with approved organizations to provide
  primary and  preventive  health  care  services  coverage  for  eligible
  children,  or  with  organizations  for  purposes  of  public education,

  outreach and recruitment of eligible children in effect  in  the  period
  January  first,  nineteen  hundred  ninety-six  through  June thirtieth,
  nineteen hundred  ninety-six  may  be  extended  for  public  education,
  outreach   and   recruitment   of  eligible  children  through  December
  thirty-first, nineteen hundred ninety-six and to provide for primary and
  preventive health care services coverage for eligible  children  through
  such  periods  for  which  such coverage continues to apply prior to the
  addition of coverage for inpatient health care services  to  provide  an
  uninterrupted  continuation  of  services  and  may be amended as may be
  necessary.
    * 16. The commissioner and the commissioner of social  services  shall
  jointly  develop  a  simplified application form for coverage under this
  title, the medical assistance program and the federal women, infants and
  children program, and shall also develop  appropriate  verification  and
  sampling  procedures  for  the  child  health insurance plan in order to
  facilitate the appropriate enrollment  of  eligible  children  into  the
  child  health  insurance  plan,  the medical assistance program, and the
  women, infants and children program. Nothing in this  subdivision  shall
  be  construed to require that eligibility documentation requirements for
  the services under this title shall  apply  to  the  medical  assistance
  program, nor shall this subdivision be construed to preclude eligibility
  for  any  person  pending  the  development  of  that  application. Such
  application  shall  be  available  for  use  by  local  social  services
  districts and approved organizations under this title by June thirtieth,
  nineteen hundred ninety-four.
    * NB Expired July 1, 2007
    16-a. The commissioner shall develop a simplified recertification form
  for  use  by  approved  organizations  in renewing coverage for eligible
  children under this title. The form shall include requests only for such
  information that is: (i) reasonably  necessary  to  determine  continued
  eligibility  for  coverage  under this title; and (ii) subject to change
  since the date of the household's initial application.
    17. The commissioner, in  consultation  with  the  superintendent,  is
  authorized  to  establish and operate a child health information service
  which shall utilize advanced telecommunications technologies to meet the
  health information and support needs of children,  parents  and  medical
  professionals,  which  shall  include,  but not be limited to, treatment
  guidelines for children,  treatment  protocols,  research  articles  and
  standards  for the care of children from birth through eighteen years of
  age. Such information shall not constitute the practice of medicine,  as
  defined in article one hundred thirty-one of the education law.
    18. Premium Assistance Program. (a) The commissioner shall establish a
  premium  assistance  program for the purchase of family coverage under a
  group health plan or health insurance coverage that includes coverage of
  an eligible child, as defined in subdivision four of section twenty-five
  hundred ten of this article, contingent upon:
    (i) a determination by the commissioner that the  purchase  of  family
  coverage under this subdivision is cost effective relative to the amount
  the  state  would pay to obtain coverage under this title solely for the
  eligible child or children; and
    (ii) the availability of federal financial participation in accordance
  with a waiver application submitted by the commissioner and approved  by
  the secretary of the department of health and human services.
    (b)  The  commissioner  shall  establish and specify standards for the
  implementation of the premium assistance program in the  federal  waiver
  application, including, but not limited to, the following:
    (i)  standards  for  eligibility  of  children  and  families  for and
  enrollment in the premium assistance program which shall include,  at  a

  minimum,  the  eligibility criteria set forth in subdivision two of this
  section; provided that:
    (A)  participation  in  the  program  for  a  child  who  resides in a
  household having a gross household income at or below two hundred  fifty
  percent of the non-farm federal poverty level (as defined and updated by
  the  United  States  department  of  health and human services) shall be
  voluntary  and  an  eligible  child  may  disenroll  from  the   premium
  assistance  program  at any time and enroll in individual coverage under
  this title; and
    (B) participation in  the  program  for  a  child  who  resides  in  a
  household  having a gross household income between two hundred fifty-one
  and four hundred percent of  the  non-farm  federal  poverty  level  (as
  defined  and updated by the United States department of health and human
  services) and meets certain eligibility criteria shall be  mandatory.  A
  child  in this income group who meets the criteria for enrollment in the
  premium assistance program shall not be eligible for individual coverage
  under this title;
    (ii) standards for required levels of  employer  contributions  toward
  the cost of premiums for family coverage;
    (iii)  standards  for  the  level  of state payment toward the cost of
  premiums for family coverage;
    (iv) standards for the scope and level of benefits to be  provided  in
  the premium assistance program;
    (v)  standards for data collection including, but not limited to, data
  regarding the substitution of health insurance coverage  that  would  be
  provided  to  eligible  children  in  the  absence  of  family  coverage
  purchased pursuant to this subdivision; and
    (vi) any other standards  deemed  necessary  by  the  commissioner  to
  implement the premium assistance program.
    (c)  The state share of the cost of the premium assistance program, if
  implemented, shall be funded within amounts appropriated for the purpose
  of providing healthcare coverage for uninsured and underinsured children
  pursuant to this title.
    19. Claims submitted to  an  approved  organization  for  payment  for
  medical  care,  services,  or  supplies  furnished  by an out-of-network
  health care provider must be submitted within fifteen months of the date
  the medical care, services, or supplies were furnished  to  an  eligible
  person to be valid and enforceable against the approved organization. If
  a  claim  by  an  out-of-network  health  care provider is not submitted
  within fifteen months of the date that the  medical  care,  services  or
  supplies  were  furnished  and  the  claim is subsequently denied by the
  approved organization for that reason, such out-of-network  health  care
  provider  shall  not  seek  payment  for  such medical care, services or
  supplies from the enrollee. This deadline for  claims  submission  shall
  not  apply  where the claims submission is warranted to address findings
  or recommendations identified in a state or federal audit  except  where
  such  audit  also  indicates  that an inappropriate provider payment was
  solely the fault of the out-of-network health care provider.
    20. For approved organizations with negotiated rates  of  payment  for
  inpatient  hospital  services  under contracts in effect on April first,
  two thousand eight, that  have  a  payment  rate  methodology  for  such
  inpatient  hospital  services  that  utilizes  rates  calculated  by the
  department of health pursuant to paragraph (a) or (a-2)  of  subdivision
  one of section twenty-eight hundred seven-c of the public health law for
  patients  under  the  medical  assistance  program,  such rate shall not
  include adjustments pursuant  to  subdivision  thirty-three  of  section
  twenty-eight  hundred seven-c of this chapter for contract periods prior
  to January first, two thousand ten.