Section 369-EE. Family health plus program

1. Definitions. (a) "Family
  health insurance plan" means the  written  undertaking  of  an  approved
  organization  to  provide  coverage  of health care services to eligible
  individuals under this title.
    (b) "Eligible organization" means  an  insurer  licensed  pursuant  to
  article  thirty-two  or forty-two of the insurance law, a corporation or
  an organization under article forty-three of the insurance  law,  or  an
  organization  certified  under  article  forty-four of the public health
  law, including providers  certified  under  section  forty-four  hundred
  three-e of such article.
    (c)  "Approved  organization" means an eligible organization which has
  been  approved  by  the  commissioner  to  underwrite  a  family  health
  insurance plan.
    (d)  "Period of eligibility" means that period commencing on the first
  day of the month following the date when the  individual  (i)  has  been
  determined  eligible  for health care coverage under this title and (ii)
  has enrolled in a family health insurance plan, and ending on  the  last
  day of the month in which an individual ceases to be eligible.
    (e)  "Health  care services" means the following services and supplies
  as defined by the commissioner in consultation with  the  superintendent
  of insurance, except as provided in subdivision three-a of this section:
    (i) the services of physicians, nurse practitioners, and other related
  personnel which are provided on an outpatient or inpatient basis;
    (ii)  inpatient  hospital  services  provided by a general hospital, a
  facility operated by the office of mental health under section  7.17  of
  the  mental  hygiene  law,  a  facility  issued an operating certificate
  pursuant to the provisions of article twenty-three or thirty-one of  the
  mental hygiene law;
    (iii) laboratory tests;
    (iv) diagnostic x-rays;
    (v)  prescription  drugs  as defined in section two hundred seventy of
  the public health law, which shall be provided pursuant  to  subdivision
  two-b  of  this section, and non-prescription smoking cessation products
  or devices;
    (vi) durable medical equipment;
    (vii) radiation therapy, chemotherapy, and hemodialysis;
    (viii) emergency room services;
    (ix) inpatient and outpatient mental health and alcohol and  substance
  abuse services, as defined by the commissioner;
    (x)  prehospital  emergency  medical  services for the treatment of an
  emergency medical condition  when  such  services  are  provided  by  an
  ambulance service;
    (xi)  emergency,  preventive  and  routine  dental care, to the extent
  offered by a family health insurance plan  described  in  this  section,
  except orthodontia and cosmetic surgery;
    (xii) emergency vision care, and preventive and routine vision care as
  follows: once in any twenty-four month period:
    (A) one eye examination;
    (B)  either:  one pair of prescription eyeglass lenses and a frame, or
  prescription contact lenses where medically necessary; and
    (C) one pair of medically necessary occupational eyeglasses;
    (xiii) speech and hearing services;
    (xiv) diabetic supplies and equipment;
    (xv) services provided to meet the requirements of 42 U.S.C. 1396d(r);
  and
    (xvi) hospice services.
    (e-1) "Health care services" shall not include: (i) drugs,  procedures
  and supplies for the treatment of erectile dysfunction when provided to,

  or  prescribed for use by, a person who is required to register as a sex
  offender pursuant to article six-C of the correction law  provided  that
  any  denial  of  coverage  pursuant  to this paragraph shall provide the
  patient  with  the  means of obtaining additional information concerning
  both the denial and the means of challenging such denial; (ii) drugs for
  the treatment of sexual or erectile dysfunction, unless such  drugs  are
  used  to  treat  a condition, other than sexual or erectile dysfunction,
  for which the drugs have been approved by  the  federal  food  and  drug
  administration.
    (f)  "Managed  care  provider"  shall  have  the  meaning set forth in
  section three hundred sixty-four-j of this article.
    (g) "Minor child" means, for purposes of this title, a child under the
  age of twenty-one.
    (h)  "Commissioner"  for  purposes  of  this  title  shall  mean   the
  commissioner of health.
    * (i)  "Resources"  for  purposes  of  this  title shall have the same
  meaning as determined in accordance with paragraph  (a)  of  subdivision
  two of section three hundred sixty-six of this article.
    * NB Repealed October 1, 2009
    2.  Eligibility.  (a)  A  person  is  eligible  to receive health care
  services pursuant to this title if he or she:
    (i) resides in New York state and is at least age nineteen, but  under
  sixty-five years of age;
    (ii) is not eligible for medical assistance under title eleven of this
  article  solely  due  to  income or resources or is eligible for medical
  assistance  under  title  eleven  of  this  article  only  through   the
  application  of  excess  income  toward  the  costs  of medical care and
  services pursuant to subdivision two of section three hundred  sixty-six
  of title eleven of this article;
    * (iii)  does not have equivalent health care coverage under insurance
  or equivalent mechanisms, as defined by the commissioner in consultation
  with the superintendent of insurance;
    * NB Effective until amendment approved by the commissioner of health
    * (iii) does not have equivalent health care coverage under  insurance
  or equivalent mechanisms, as defined by the commissioner in consultation
  with the superintendent of insurance;
    * NB Effective upon approval by the commissioner of health
    * (iv)  (A)  was  not covered by a group health plan based upon his or
  her employment or 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:
    (I) loss of employment due to factors other than voluntary separation;
    (II)  death  of  a  family  member which results in termination of the
  applicant's coverage under the group health plan;
    (III) change to a new employer that does not  provide  an  option  for
  comprehensive health benefits coverage;
    (IV)  change  of  residence  so  that  no employer-based comprehensive
  health benefits coverage is available;
    (V) discontinuation of comprehensive health benefits coverage  to  all
  employees of the applicant's employer;
    (VI)  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;
    (VII)  termination  of  comprehensive  health benefits coverage due to
  long-term disability;

    (VIII) loss of employment due to need to care for a child or  disabled
  household member or relative; or
    (IX)  reduction  in  wages  or  hours  or  an  increase in the cost of
  coverage so that coverage is no longer affordable or available.
    (B) the implementation of this subparagraph  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 pursuant to subparagraph (ii) of paragraph  (d)  of
  subdivision  two  of  section  twenty-five  hundred eleven of the public
  health law.
    * NB Effective until amendment approved by the commissioner of health
    * (iv) (A) was not covered by a group health plan based  upon  his  or
  her  employment  or  a  family  member's  employment,  as defined by the
  commissioner in  consultation  with  the  superintendent  of  insurance,
  during  the nine-month period prior to the date of the application under
  this title, except in the case of:
    (I) loss of employment due to factors other than voluntary separation;
    (II) death of a family member which  results  in  termination  of  the
  applicant's coverage under the group health plan;
    (III)  change  to  a  new employer that does not provide an option for
  comprehensive health benefits coverage;
    (IV) change of  residence  so  that  no  employer-based  comprehensive
  health benefits coverage is available;
    (V)  discontinuation  of comprehensive health benefits coverage to all
  employees of the applicant's employer;
    (VI) 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;
    (VII) termination of comprehensive health  benefits  coverage  due  to
  long-term disability;
    (VIII)  loss of employment due to need to care for a child or disabled
  household member or relative; or
    (IX) reduction in wages or  hours  or  an  increase  in  the  cost  of
  coverage so that coverage is no longer affordable or available.
    (B)  the  implementation  of  this subparagraph 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  pursuant to subparagraph (ii) of paragraph (d) of
  subdivision two of section twenty-five  hundred  eleven  of  the  public
  health law.
    * NB Effective upon approval by the commissioner of health
    * (v)  (A)  in the case of a parent or stepparent of a child under the
  age of twenty-one who lives with such child,  has  gross  family  income
  equal  to  or  less  than  the  applicable percent of the federal income
  official poverty line (as defined  and  updated  by  the  United  States
  Department  of Health and Human Services) for a family of the same size;
  for purposes of this clause, the applicable percent effective as of:
    (I) January first, two thousand one, is one  hundred  twenty  percent;
  and
    (II)  October  first,  two  thousand  one, is one hundred thirty-three
  percent; and
    (III) October first, two thousand two, is one hundred  fifty  percent;
  or
    (B)  in  the  case  of an individual who is not a parent or stepparent
  living with his or her child under the  age  of  twenty-one,  has  gross
  family  income  equal to or less than one hundred percent of the federal

  income official poverty line (as  defined  and  updated  by  the  United
  States Department of Health and Human Services) for a family of the same
  size.
    * NB Effective until April 1, 2010
    * (v)  (A)  in the case of a parent or stepparent of a child under the
  age of twenty-one who lives with such child,  has  gross  family  income
  equal  to  or  less  than  the  applicable percent of the federal income
  official poverty line (as defined  and  updated  by  the  United  States
  Department  of Health and Human Services) for a family of the same size;
  for purposes of this clause, the applicable percent effective as of:
    (I) January first, two thousand one, is one  hundred  twenty  percent;
  and
    (II)  October  first,  two  thousand  one, is one hundred thirty-three
  percent; and
    (III) October first, two thousand two, is one hundred  fifty  percent;
  and
    (IV) April first, two thousand ten, is one hundred sixty percent; or
    (B)  in  the case of an individual who is at least twenty-one years of
  age and who is not a parent or stepparent living with his or  her  child
  under  the  age  of twenty-one, has gross family income equal to or less
  than one hundred percent of the federal income official poverty line (as
  defined and updated by the United States Department of Health and  Human
  Services) for a family of the same size; or
    (C)  in  the  case of an individual who is at least nineteen but under
  twenty-one years of age and who is not a  parent  or  stepparent  living
  with  his  or  her  child  under the age of twenty-one, has gross family
  income equal to or less than one hundred sixty percent  of  the  federal
  income  official  poverty  line  (as  defined  and updated by the United
  States Department of Health and Human Services) for a family of the same
  size; or
    (D) is not described in clause (A), (B) or (C)  of  this  subparagraph
  and has gross family income equal to or less than two hundred percent of
  the  federal income official poverty line (as defined and updated by the
  United States Department of Health and Human Services) for a  family  of
  the  same size; provided, however, that eligibility under this clause is
  subject to sources of federal and non-federal funding for  such  purpose
  described  in  section  sixty-seven-a  of the chapter of the laws of two
  thousand nine that added this clause or as may be  available  under  the
  waiver  agreement entered into with the federal government under section
  eleven hundred fifteen of the federal social security  act,  as  jointly
  determined  by  the commissioner and the director of the division of the
  budget. In no  case  shall  state  funds  be  utilized  to  support  the
  non-federal   share  of  expenditures  pursuant  to  this  subparagraph,
  provided however that the commissioner may  demonstrate  to  the  United
  States  department  of  health  and  human  services  the  existence  of
  non-federally participating state expenditures as  necessary  to  secure
  federal  funding under an eleven hundred fifteen waiver for the purposes
  herein. Eligibility under this clause may be provided  to  residents  of
  all  counties  or,  at  the joint discretion of the commissioner and the
  director of the division of the budget, a  subset  of  counties  of  the
  state.
    * NB Effective April 1, 2010
    (b)  * Subject to the provisions of paragraph (d) of this subdivision,
  in order to establish income  eligibility  under  this  subdivision,  an
  individual   shall  provide  such  documentation  as  is  necessary  and
  sufficient  to  initially,  and  annually   thereafter,   determine   an
  applicant's   eligibility   for   coverage   under   this   title.  Such

  documentation shall include, but not be limited  to  the  following,  if
  needed to verify eligibility:
    * NB Effective until October 1, 2009
    * Subject  to  the provisions of paragraph (d) of this subdivision, in
  order to establish eligibility under this subdivision,  which  shall  be
  determined without regard to resources, an individual shall provide such
  documentation  as is necessary and sufficient to initially, and annually
  thereafter, determine an applicant's eligibility for coverage under this
  title. Such documentation shall include,  but  not  be  limited  to  the
  following, if needed to verify eligibility:
    * NB Effective October 1, 2009
    (i) paycheck stubs; or
    (ii) written documentation of income from all employers; or
    (iii) other documentation of income (earned or unearned) as determined
  by  the  commissioner,  provided  however,  such documentation shall set
  forth the source of such income; and
    (iv)  proof  of  identity  and  residence   as   determined   by   the
  commissioner.
    The  commissioner of health may verify the accuracy of the information
  provided by the individual pursuant to this  paragraph  by  matching  it
  against  information  to  which  the  commissioner  of health has access
  including under subdivision eight of section three  hundred  sixty-six-a
  of this article.
    *(c)  For  the  purposes of this title, the determination of resources
  shall be in accordance with paragraphs (b) and (c) of subdivision two of
  section three hundred sixty-six-a of this article.
    * NB Repealed October 1, 2009
    * (d) In order to establish place of residence and income  eligibility
  under  this  title  at  recertification, a recipient of assistance under
  this title shall attest to place of residence  and  to  all  information
  regarding  the  household's  income  that is necessary and sufficient to
  determine such eligibility. The commissioner of health shall verify  the
  accuracy  of  the information provided by the recipient pursuant to this
  paragraph by matching it against information to which  the  commissioner
  of health has access, including under subdivision eight of section three
  hundred   sixty-six-a  of  this  article.  In  the  event  there  is  an
  inconsistency between the information reported by the recipient and  any
  information  obtained  by  the commissioner of health from other sources
  and such inconsistency is material to eligibility under this title,  the
  commissioner of health shall request that the recipient provide adequate
  documentation  to  verify  his  or  her place of residence or income, as
  applicable. In addition to the documentation  of  residence  and  income
  authorized  by  this paragraph, the commissioner of health is authorized
  to periodically require a reasonable sample  of  recipients  to  provide
  documentation   of   residence   and   income  at  recertification.  The
  commissioner of health shall consult with the medicaid inspector general
  regarding income and residence  verification  practices  and  procedures
  necessary to maintain program integrity and deter fraud and abuse.
    * NB There are 2 ù (d)'s
    * (d)  For purposes of determining income eligibility pursuant to this
  subdivision, depreciation of assets owned by a self-employed  individual
  operating  a  farm  operation as defined in section three hundred one of
  the agriculture and markets law, as included  on  the  Internal  Revenue
  Service  Form 1040 of the applicable year, shall not be included as part
  of the gross family income. If all necessary approvals relating to  this
  paragraph  under  federal  law  and regulation have not been obtained to
  receive federal financial participation, then this paragraph  shall  not

  apply;  however, that shall not affect the status of any other provision
  of this title.
    * NB There are 2 ù (d)'s
    2-a.  Co-payments. Subject to federal approval pursuant to subdivision
  six of this section, persons receiving family health plus coverage under
  this section shall be responsible to make co-payments in accordance with
  the terms of subdivision six of section three hundred  sixty-seven-a  of
  this  article,  including  those  individuals who are otherwise exempted
  under  the  provisions  of  subparagraph  (iv)  of  paragraph   (b)   of
  subdivision  six of section three hundred sixty-seven-a of this article,
  provided however, that notwithstanding the provisions of paragraphs  (c)
  and (d) of such subdivision:
    (i)  co-payments  charged for each generic prescription drug dispensed
  shall be three  dollars  and  for  each  brand  name  prescription  drug
  dispensed shall be six dollars;
    (ii)  the  co-payment  charged  for each dental service visit shall be
  five dollars, provided that no enrollee shall be required  to  pay  more
  than  twenty-five  dollars  per year in co-payments for dental services;
  and
    (iii) the co-payment for clinic services and physician services  shall
  be five dollars;
  and  provided  further  that  the  limitations  in paragraph (f) of such
  subdivision shall not apply.
    2-b. Prescription drug payments. (a) Subject to paragraph (b) of  this
  subdivision,  payment  for  drugs,  except  for  such  drugs provided by
  medical practitioners, and for which payment is authorized  pursuant  to
  paragraph (e) of subdivision one of this section, shall be made pursuant
  to  subdivision  nine  of  section  three  hundred sixty-seven-a of this
  article and article two-A of the public health law and subdivision  four
  of  section three hundred sixty-five-a of this article. Payment for such
  drugs provided  by  medical  practitioners  shall  be  included  in  the
  capitation payment for services or supplies provided to persons eligible
  for health care services under this title.
    (b)  Payment  for  drugs  for  which payment is authorized pursuant to
  paragraph (e) of subdivision one of this section, and that are  provided
  by  an  employer  partnership  for family health plus plan authorized by
  section three hundred sixty-nine-ff of this title, shall be included  in
  the  capitation  payment  for  services  or supplies provided to persons
  eligible for health care services under such plan.
    3. (a) Except as provided in  subdivision  three-a  of  this  section,
  every  person  determined  eligible  for or receiving family health plus
  coverage under this section shall enroll in a  family  health  insurance
  plan.
    (b)  Participants  shall  select  a  family health insurance plan from
  among those  designated  under  the  family  health  plus  program.  (i)
  Notwithstanding  any  provision of law to the contrary, the commissioner
  may assign persons to a family health insurance  plan  when  failure  to
  enroll  in  a  plan  would result in a lapse in ongoing health insurance
  program coverage.
    (ii) Participants shall be notified sixty days in advance of the  need
  to  change  their family health insurance plan and given the opportunity
  to  select  a  new  plan  prior  to  being  assigned  to  a  plan  under
  subparagraph (i) of this paragraph.
    (iii)  When  it is necessary for an individual to change family health
  insurance plans with less  than  sixty  days  notice,  the  notification
  required by subparagraph (ii) of this paragraph is waived, provided that
  the  department  shall  notify  recipients after being auto-assigned and

  allow them thirty days from such notification  to  switch  their  family
  health insurance plan.
    (c)  Participants  under  this section who have lost their eligibility
  for health care services  before  the  end  of  a  twelve  month  period
  beginning  on  the  date  of  the  participant's initial enrollment in a
  family health insurance plan, or before the end of a twelve month period
  beginning on the date of any subsequent  determination  of  eligibility,
  shall  have their eligibility for family health plus continued until the
  end  of  the  twelve  month  period,  provided  that  federal  financial
  participation  in  the  cost of such coverage is available; and provided
  further that such participants who cease to be eligible because they  no
  longer  reside in New York state, or who have access to or have obtained
  other health insurance coverage,  as  defined  by  the  commissioner  in
  consultation with the superintendent of insurance, shall not be eligible
  for the extended enrollment described in this paragraph.
    (d)  Family health insurance plans shall assure access to and delivery
  of high quality, cost effective, appropriate health care services.  Such
  plans  shall  include  a  network of health care providers in sufficient
  numbers which are  geographically  accessible  to  program  participants
  consistent with the following provisions:
    (i)  approved  organizations  shall adhere to marketing and enrollment
  guidelines established by the commissioner, which shall include but  not
  be  limited  to  marketing  and  enrollment  encounters between approved
  organizations and prospective enrollees, locations for such  encounters,
  and   prohibitions   against  telephone  cold-calling  and  door-to-door
  solicitation  at  the   homes   of   prospective   enrollees.   Approved
  organizations  shall  be  permitted  to  assist prospective enrollees in
  completion of enrollment forms at approved health  care  provider  sites
  and other approved locations. In no case may an emergency room be deemed
  an  approved  location.  Approved  organizations shall submit enrollment
  forms to the local department of social services.
    (ii) any marketing materials developed  by  an  approved  organization
  shall be approved by the department of health within sixty days prior to
  distribution to prospective enrollees of family health insurance.
    (iii)  a  family  health  insurance plan requesting disenrollment of a
  participant shall not disenroll a participant without the prior approval
  of the local district in which the participant resides. A family  health
  insurance plan shall not request disenrollment of a participant based on
  any  diagnosis,  condition,  or  perceived  diagnosis or condition, or a
  participant's efforts to exercise his or her rights  under  a  grievance
  process.
    (iv)  a  family  health  insurance  plan shall implement procedures to
  communicate  appropriately  with  participants   who   have   difficulty
  communicating   in   English   and  to  communicate  appropriately  with
  visually-impaired and hearing-impaired participants.
    (v) a family health insurance plan shall comply with applicable  state
  and  federal  law  provisions prohibiting discrimination on the basis of
  disability.
    (vi) a family health insurance  plan  shall  establish  procedures  to
  comply  with  subparagraph (iii) of paragraph (a) of subdivision four of
  section three hundred sixty-four-j of this article.
    (e) The family health plus  program  shall  be  operated  by  approved
  organizations  which  are  authorized  to  arrange for care and services
  pursuant  to  this  section  provided  however  that,  unless  otherwise
  specified in this title, paragraphs (c), (s), (t) and (u) of subdivision
  one,  paragraph  (b)  of  subdivision two, subdivision three, paragraphs
  (b), (c), (d), subparagraphs (i), (iv), (v), (vi), (vii), and (viii)  of
  paragraph  (e),  paragraphs  (f),  (g), (i) and (l) of subdivision four,

  subdivisions  five,  seven,  eleven  and  twelve,   paragraph   (a)   of
  subdivision  thirteen,  subdivisions  fourteen,  fifteen  and seventeen,
  paragraph (b)  of  subdivision  eighteen  and  subdivisions  twenty  and
  twenty-one  of  section three hundred sixty-four-j of this article shall
  not apply and provided further that provisions addressing  provision  of
  benefits by special needs plans shall not apply.
    (f)  Notwithstanding  any  inconsistent  provisions  of this title and
  section one hundred sixty-three  of  the  state  finance  law:  (i)  the
  commissioner  may  contract  with  managed care providers approved under
  section three hundred sixty-four-j of this article  or  title  one-A  of
  article  twenty-five  of the public health law without a competitive bid
  or request for proposal  process  to  provide  family  health  insurance
  coverage  for eligible individuals pursuant to this title; (ii) in areas
  of the state which do not have sufficient managed care  access  to  meet
  the  objectives  of  this  section,  the  commissioner may contract with
  entities approved pursuant to title one-A of article twenty-five of  the
  public health law.
    (g)  The  care  and  services  described under subdivision one of this
  section will be furnished by a family health insurance plan pursuant  to
  the  provisions  of  this  section  when  such services are furnished in
  accordance with an agreement with the  department  of  health  and  meet
  applicable federal laws and regulations.
    (h)  The commissioner may delegate some or all of the tasks identified
  in this section to local districts provided that the  agreement  between
  the  department  of  health  and  such plan pursuant to this subdivision
  clearly reflects such delegation.
    (i) Claims submitted to a family health insurance plan 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 family  health  insurance
  plan.  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.
    (j) Family health insurance plans 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  the  public  health  law  for  contract
  periods prior to January first, two thousand ten.
    3-a.  (a)  A  person  who meets the requirements of subdivision two of
  this section shall not be enrolled in, or shall be disenrolled  from,  a
  family health insurance plan if a determination has been made that:
    (i)  the  person has access to employer-sponsored health insurance, as
  defined by the commissioner; and
    (ii) furnishing the health care services described in paragraph (c) of
  this subdivision is deemed cost effective by the commissioner.
    (b) If a determination is made that a person meets  the  criteria  set
  forth in paragraph (a) of this subdivision, the person shall be required
  to enroll in the employer-sponsored health insurance in order to receive
  or continue to receive health care services under this section. A person
  required  to  enroll  in employer-sponsored health insurance pursuant to

  this subdivision shall not, by  virtue  of  having  such  insurance,  be
  deemed   to  have  equivalent  health  care  coverage  for  purposes  of
  subparagraph (iii) of paragraph (a) of subdivision two of this section.
    (c)  With  respect  to  a  person  described  in paragraph (a) of this
  subdivision who has  enrolled  in  employer-sponsored  health  insurance
  pursuant  to  paragraph  (b)  of  this subdivision, health care services
  pursuant to this title shall mean:
    (i)  payment  or  part-payment  of  the  premium,  co-insurance,   any
  deductible  amounts  and other cost-sharing obligations for the person's
  employer-sponsored health  insurance  that  exceed  the  amount  of  the
  person's  co-payment obligation under subdivision two-a of this section;
  and
    (ii) payment for services and supplies  listed  in  paragraph  (e)  of
  subdivision  one  of  this section, subject to any limitations contained
  therein and in paragraph (e-1) of such  subdivision,  but  only  to  the
  extent  that  such services and supplies are not covered by the person's
  employer-sponsored health insurance.
    4. (a) The commissioner shall develop and  implement  locally-tailored
  education,  outreach  and  facilitated enrollment strategies targeted to
  individuals who may be eligible for benefits under this title  or  title
  eleven  of  this  article.  Such  strategies  shall  include, but not be
  limited to, contracting with community-based  organizations  to  perform
  education,   outreach   and  facilitated  enrollment.  In  awarding  the
  contracts, the commissioner shall  consider  the  extent  to  which  the
  organizations,  or  coalitions  of  organizations,  are  able  to target
  efforts effectively in  geographic  areas  in  which  there  is  a  high
  proportion  of  uninsured  individuals  and a low proportion of eligible
  individuals receiving benefits under title eleven of  this  article.  In
  approving   organizations  to  undertake  activities  pursuant  to  this
  subdivision, within a defined geographic region, the commissioner  shall
  make  a  good  faith effort to ensure that the organizations are broadly
  inclusive of organizations in the  region  able  to  target  effectively
  individuals  who  may be eligible for coverage under this title or title
  eleven of this article.
    (b) Outreach strategies shall include but shall not be limited to:
    (i) public education;
    (ii) dissemination of materials regarding the availability of benefits
  available under this title, title eleven  of  this  article,  and  title
  one-A  of  article  twenty-five  of the public health law, provided that
  such  materials  have  been  approved  by  the  commissioner  prior   to
  distribution;
    (iii)  development  of  an  application  form  for services under this
  program and for services under title eleven of this article that is easy
  to understand and complete;
    (iv) outstationing of persons who are authorized to provide assistance
  to individuals in completing the application process under  this  title,
  title  eleven of this article, and title one-A of article twenty-five of
  the public health law  including  the  conduct  of  personal  interviews
  pursuant  to  section  three  hundred  sixty-six-a  of this chapter upon
  initial application. Such locations shall include but not be limited  to
  offices  of approved organizations, which shall be authorized to conduct
  personal interviews. Outstationing shall take place in  locations  which
  are geographically accessible to large numbers of individuals who may be
  eligible  for  benefits  under  such  titles,  and  at  times, including
  evenings and weekends, when large numbers  of  individuals  who  may  be
  eligible for benefits under such titles are likely to be encountered. In
  the  event  that  a  photograph  of  the  participant is required for an
  identification  card,  other  than  a   photograph   supplied   by   the

  participant, the commissioner shall exercise best efforts to assure that
  such  photograph  can  be  taken in geographically accessible locations,
  including the offices of approved organizations.
    (c) The commissioner shall:
    (i)  ensure  that  training  is furnished for outstationed persons and
  employees of  approved  organizations  to  enable  them  to  disseminate
  information  and  facilitate  the  completion of the application process
  under this title, title eleven of  this  article,  and  title  one-A  of
  article twenty-five of the public health law;
    (ii)  ensure  that outreach strategies and activities under this title
  are coordinated with such strategies and activities under title one-A of
  article twenty-five of the public health  law,  and  with  all  approved
  organizations,  enrollment  brokers,  and  other relevant entities under
  this title, title eleven of this article  and  title  one-A  of  article
  twenty-five of the public health law;
    (iii)  periodically  monitor  the  performance of entities involved in
  outreach activities, to assure  that  potentially  eligible  individuals
  receive  accurate  information  in  a  understandable  manner, that such
  individuals are told of the availability of benefits under  this  title,
  title  eleven  of this article and title one-A of article twenty-five of
  the public health  law,  that  such  individuals  are  informed  of  the
  approved  organizations  under this title, title eleven of this article,
  and title one-A of article twenty-five of the  public  health  law,  and
  that  appropriate follow-up is conducted. Such monitoring shall include,
  but shall 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 title eleven of this article.
    (d)   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.
    5.  * (a)  Personal  interviews,  pursuant  to  section  three hundred
  sixty-six-a of this chapter, may be required  upon  initial  application
  only  and  may  be  conducted  in community settings. Recertification of
  eligibility shall take place on no more than an annual basis  and  shall
  not  require  a  personal  interview.  Nothing  herein shall abridge the
  participant's obligation  to  report  changes  in  residency,  financial
  circumstances or household composition.
    * NB Effective until April 1, 2010
    * (a)  A  personal interview with the applicant or with the person who
  made application on his or her behalf shall not be required as part of a
  determination of initial or  continuing  eligibility  pursuant  to  this
  title.  Recertification  of eligibility shall take place on no more than
  an  annual  basis.  Nothing  herein  shall  abridge  the   participant's
  obligation  to  report  changes in residency, financial circumstances or
  household composition.
    * NB Effective April 1, 2010
    (b) Sections twenty-three and twenty-three-a of chapter  four  hundred
  thirty-six  of the laws of nineteen hundred ninety-seven shall not apply
  to applicants for or recipients  of  health  care  services  under  this
  title.

    (c)  Except  where inconsistent with the provisions of this title, the
  provisions of title eleven of this article shall apply to applicants for
  and recipients under this title.
    * 6. Waivers and federal approvals. (a) The provisions of this section
  shall  not  take effect unless all necessary approvals under federal law
  and  regulation  have  been  obtained  to  receive   federal   financial
  participation,  under  the  program  described  in  title eleven of this
  article, in the costs of health care services provided pursuant to  this
  section.
    (b)  The  commissioner is authorized to submit amendments to the state
  plan for medical assistance and/or submit one or more  applications  for
  waivers  of  the  federal  social  security  act,  to obtain the federal
  approvals necessary to implement this section.  The  commissioner  shall
  submit   such   amendments  and/or  applications  for  waivers  by  June
  thirtieth, two thousand, and  shall  use  best  efforts  to  obtain  the
  approvals required by this subdivision in a timely manner so as to allow
  early implementation of this section.
    * NB U.S. Sec. of Health and Human Services granted approval per §1115
  of Social Security Act on June 1, 2001
    7.  The  commissioner  shall  promulgate  any regulations necessary to
  implement this title.