N.Y. ISC Law § 4322-A — New York Code / Act ISC / Article 43 / Section 4322-A
Fund for standardized individual enrollee direct payment contracts which provide out-of-plan benefits
Status: in_force

§ 4322-a. Fund for standardized individual enrollee direct payment\ncontracts which provide out-of-plan benefits. (a) The superintendent\nshall establish a fund from which health maintenance organizations may\nreceive reimbursement, to the extent of funds available therefor, for\nclaims paid by such health maintenance organizations for members covered\nunder standardized individual enrollee direct payment contracts which\nprovide out-of-plan benefits issued pursuant to section four thousand\nthree hundred twenty-two of this article. The fund established by the\nsuperintendent pursuant to this section shall be known as "the direct\npayment out-of-plan stop loss fund". Commencing in calendar year two\nthousand, health maintenance organizations shall be eligible to receive\nreimbursement from the direct payment out-of-plan stop loss fund for\nninety percent of claims paid between twenty thousand and one hundred\nthousand dollars in a calendar year for any member covered under a\ncontract issued pursuant to section four thousand three hundred\ntwenty-two of this article. For the purposes of this section, claims\nshall include health care claims paid by a health maintenance\norganization on behalf of a covered member pursuant to contracts issued\npursuant to section four thousand three hundred twenty-two of this\narticle.\n  (b) The superintendent shall promulgate regulations that set forth\nprocedures for the operation of the direct payment out-of-plan stop loss\nfund and the distribution of monies therefrom.\n  (c) Claims shall be reported and funds shall be distributed on a\ncalendar year basis. Claims shall be eligible for reimbursement only for\nthe calendar year in which the claims are paid. Once claims paid on\nbehalf of a member reach or exceed one hundred thousand dollars in a\ngiven calendar year, no further claims paid on behalf of such member in\nthat calendar year shall be eligible for reimbursement.\n  (d) Each health maintenance organization shall submit a request for\nreimbursement from the stop loss fund on a form prescribed by the\nsuperintendent. Such request for reimbursement shall be submitted no\nlater than April first following the end of the calendar year for which\nthe reimbursement request is being made. The superintendent may require\nhealth maintenance organizations to submit such claims data in\nconnection with the reimbursement request as he deems necessary to\nenable him to distribute monies and oversee the operation of the direct\npayment out-of-plan stop loss fund. The superintendent may require that\nsuch data be submitted on a per member, aggregate and/or categorical\nbasis.\n  (e) The superintendent shall calculate the total claims reimbursement\namount for all health maintenance organizations for the calendar year\nfor which claims are being reported.\n  (1) In the event that the total amount requested for reimbursement by\nall health maintenance organizations for a calendar year exceeds funds\navailable for distribution for claims paid by all health maintenance\norganizations during that same calendar year, the superintendent shall\nprovide for the pro-rata distribution of the available funds. Each\nhealth maintenance organization shall be eligible to receive only such\nproportionate amount of the available funds as the individual health\nmaintenance organization's total eligible claims bears to the total\neligible claims paid by all health maintenance organizations.\n  (2) In the event that (A) funds available for distribution for claims\npaid by all health maintenance organizations during a calendar year\nexceeds the total amount requested for reimbursement by all health\nmaintenance organizations during that same calendar year, and (B) the\ntotal amount requested for reimbursement by all health maintenance\norganizations from the direct payment stop loss fund exceeds the amount\navailable for distribution from such fund, then any excess funds shall\nbe reallocated for distribution to the direct payment stop loss fund.\nOtherwise, such excess funds shall be carried forward and shall not\naffect the monies appropriated for the direct payment out-of-plan stop\nloss fund in the next calendar year.\n  (f) Upon the request of the superintendent, each health maintenance\norganization shall be required to furnish such data as the\nsuperintendent deems necessary to oversee the operation of the direct\npayment out-of-plan stop loss fund. Such data shall be furnished in a\nform prescribed by the superintendent.\n  (g) The superintendent may obtain the services of an organization to\nadminister the direct payment out-of-plan stop loss fund. The\nsuperintendent shall establish guidelines for the submission of\nproposals by organizations for the purposes of administering the fund.\nThe superintendent shall make a determination whether to approve,\ndisapprove or recommend modification to the proposal of an applicant to\nadminister the fund. An organization approved to administer the fund\nshall submit reports to the superintendent in such form and at times as\nmay be required by the superintendent in order to facilitate evaluation\nand ensure orderly operation of the fund, including, but not limited to,\nan annual report of the affairs and operations of the fund, such report\nto be delivered to the superintendent and to the chairs of the senate\nfinance committee and assembly ways and means committee. An organization\napproved to administer the fund shall maintain records in a form\nprescribed by the superintendent and which shall be available for\ninspection by or at the request of the superintendent. The\nsuperintendent shall determine the amount of compensation to be\nallocated to an approved organization as payment for fund\nadministration. Compensation shall be payable from the direct payment\nout-of-plan stop loss fund. An organization approved to administer the\nfund may be removed by the superintendent and must cooperate in the\norderly transition of services to another approved organization or to\nthe superintendent.\n  (h) If the superintendent deems it appropriate for the proper\nadministration of the direct payment out-of-plan stop loss fund, the\nadministrator of the fund, on behalf of and with the prior approval of\nthe superintendent, shall be authorized to purchase stop loss insurance\nand/or reinsurance from an insurance company licensed to write such type\nof insurance in this state. Such stop loss insurance and/or reinsurance\nmay be purchased to the extent of funds available therefor within such\nfunds which are available for purposes of the stop loss fund.\n