NY Ins L § 4322-A (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4322-A - Fund for Standardized Individual Enrollee Direct Payment Contracts Which Provide Out-of-Plan Benefits.

§  4322-a.  Fund  for  standardized individual enrollee direct payment contracts which provide out-of-plan  benefits.  (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 which provide out-of-plan benefits issued pursuant to  section  four  thousand three  hundred  twenty-two  of this article. The fund established by the superintendent pursuant to this section shall be known  as  "the  direct payment  out-of-plan  stop  loss  fund". Commencing in calendar year two thousand, health maintenance organizations shall be eligible to  receive reimbursement  from  the  direct  payment out-of-plan 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-two  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 contracts issued pursuant to section four  thousand  three  hundred  twenty-two  of  this article.  (b)  The  superintendent  shall  promulgate regulations that set forth procedures for the operation of the direct payment out-of-plan 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 that 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 out-of-plan 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  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 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 stop loss fund. Otherwise, such excess funds shall be  carried  forward  and  shall  not affect  the  monies appropriated for the direct payment out-of-plan 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  out-of-plan  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  out-of-plan  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 out-of-plan  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 out-of-plan 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.