NY Ins L § 4321-A (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4321-A - Fund for Standardized Individual Enrollee Direct Payment Contracts.

§  4321-a.  Fund  for  standardized individual enrollee direct payment contracts. (a) The superintendent shall  establish  a  fund  from  which health  maintenance  organizations  may  receive  reimbursement,  to the extent of funds available therefor,  for  claims  paid  by  such  health maintenance   organizations   for  members  covered  under  standardized individual enrollee direct payment contracts issued pursuant to  section four  thousand  three  hundred  twenty-one  of  this  article.  The fund established by the superintendent pursuant  to  this  section  shall  be known  as the direct payment stop loss fund. Commencing in calendar year two thousand, health maintenance  organizations  shall  be  eligible  to receive  reimbursement from the direct payment stop loss fund for ninety percent of claims paid between twenty thousand and one hundred  thousand dollars  in  a  calendar  year  for  any member covered under a contract issued pursuant to section four thousand  three  hundred  twenty-one  of this  article.  For  the  purposes of this section, claims shall include health care claims paid by a health maintenance organization  on  behalf of  a  covered  member  pursuant  to  such  standardized  direct payment contracts.  (b) The superintendent  shall  promulgate  regulations  setting  forth procedures  for  the  operation of the direct payment stop loss fund and the distribution of monies therefrom.  (c) Claims shall be reported and  funds  shall  be  distributed  on  a calendar year basis. Claims shall be eligible for reimbursement only for the  calendar  year  in  which  the claims are paid. Once claims paid on behalf of a member reach or exceed one hundred  thousand  dollars  in  a given  calendar year, no further claims paid on behalf of such member in such calendar year shall be eligible for reimbursement.  (d) Each health maintenance organization shall submit  a  request  for reimbursement  from  the  stop  loss  fund  on  a form prescribed by the superintendent. Such request for reimbursement  shall  be  submitted  no later  than April first following the end of the calendar year for which the reimbursement request is being made. The superintendent may  require health   maintenance   organizations  to  submit  such  claims  data  in connection with the reimbursement  request  as  he  deems  necessary  to enable  him to distribute monies and oversee the operation of the direct payment stop loss fund. The superintendent may require that such data be submitted on a per member, aggregate and/or categorical basis.  (e) The superintendent shall calculate the total claims  reimbursement amount  for  all  health maintenance organizations for the calendar year for which claims are being reported.  (1) In the event that the total amount requested for reimbursement  by all  health  maintenance organizations for a calendar year exceeds funds available for distribution for claims paid  by  all  health  maintenance organizations  during  that same calendar year, the superintendent shall provide for the pro-rata  distribution  of  the  available  funds.  Each health  maintenance  organization shall be eligible to receive only such proportionate amount of the available funds  as  the  individual  health maintenance organization's total eligible claims paid bears to the total eligible claims paid by all health maintenance organizations.  (2)  In the event that (A) funds available for distribution for claims paid by all health maintenance  organizations  during  a  calendar  year exceeds  the  total  amount  requested  for  reimbursement by all health maintenance organizations during that same calendar year,  and  (B)  the total  amount  requested  for  reimbursement  by  all health maintenance organizations from the direct payment out-of-plan stop loss fund exceeds the amount available for distribution from such fund,  then  any  excess funds  shall  be  reallocated  for  distribution  to  the direct payment out-of-plan stop loss  fund.  Otherwise,  such  excess  funds  shall  be  carried  forward  and will not affect monies appropriated for the direct payment stop loss fund in the next calendar year.  (f)  Upon  the  request of the superintendent, each health maintenance organization  shall  be  required  to   furnish   such   data   as   the superintendent  deems  necessary  to oversee the operation of the direct payment stop  loss  fund.  Such  data  shall  be  furnished  in  a  form prescribed by the superintendent.  (g)  The  superintendent may obtain the services of an organization to administer the direct payment stop loss fund. The  superintendent  shall establish  guidelines  for  the submission of proposals by organizations for the purposes of administering the  fund.  The  superintendent  shall make  a  determination  whether  to  approve,  disapprove  or  recommend modification to the proposal of an applicant to administer the fund.  An organization approved to administer the fund shall submit reports to the superintendent  in  such  form  and  at  times as may be required by the superintendent in order to  facilitate  evaluation  and  ensure  orderly operation of the fund, including, but not limited to an annual report of the  affairs  and operations of the fund, such report to be delivered to the superintendent and to the chairs of the senate finance committee and assembly  ways  and  means  committee.  An  organization   approved   to administer  the  fund shall maintain records in a form prescribed by the superintendent and which shall be available for inspection by or at  the request  of  the  superintendent. The superintendent shall determine the amount of compensation to be allocated to an  approved  organization  as payment  for fund administration. Compensation shall be payable from the direct payment stop loss fund. An organization  approved  to  administer the  fund may be removed by the superintendent and must cooperate in the orderly transition of services to another approved  organization  or  to the superintendent.  (h)  If  the  superintendent  deems  it  appropriate  for  the  proper administration of the direct payment stop loss fund,  the  administrator of  the  fund,  on  behalf  of  and  with  the  prior  approval  of  the superintendent, shall be authorized  to  purchase  stop  loss  insurance and/or reinsurance from an insurance company licensed to write such type of  insurance in this state. Such stop loss insurance and/or reinsurance may be purchased to the extent of funds available therefor  within  such funds which are available for purposes of the stop loss fund.