NY Ins L § 4327 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4327 - Stop Loss Funds for Standardized Health Insurance Contracts Issued to Qualifying Small Employers and Qualifying Individuals.

§  4327.  Stop  loss funds for standardized health insurance contracts issued to qualifying small employers and qualifying individuals. (a) The superintendent shall establish a  fund  from  which  health  maintenance organizations,  corporations  or  insurers may receive reimbursement, to the extent of funds available therefor, for claims paid by  such  health maintenance  organizations, corporations or insurers for members covered under qualifying group health insurance  contracts  issued  pursuant  to section  four  thousand  three  hundred twenty-six of this article. This fund shall be known as the "small employer stop loss fund".  (b) Health maintenance organizations, corporations or  insurers  shall be  eligible  to receive reimbursement for ninety percent of claims paid between five thousand and seventy-five thousand dollars  in  a  calendar year  for  any  member  covered  under  a  standardized  contract issued pursuant to section four  thousand  three  hundred  twenty-six  of  this article.  Claims  paid for members covered under qualifying group health insurance contracts shall be reimbursable from the small  employer  stop loss fund. 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 contracts.  (c) The superintendent shall promulgate  regulations  that  set  forth procedures  for  the  operation of the small employer stop loss fund and distribution of monies therefrom.  (d) The superintendent may adjust the  level  of  stop  loss  coverage specified in subsection (b) of this section.  (e)  Claims  shall be reported and funds shall be distributed from the small employer stop loss fund 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 covered 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.  (f) Each health maintenance organization, corporation or insurer shall submit  a  request  for  reimbursement  from the stop loss fund on forms prescribed by the superintendent. The requests for  reimbursement  shall be submitted no later than April first following the end of the calendar year   for   which  the  reimbursement  requests  are  being  made.  The superintendent   may   require   health    maintenance    organizations, corporations  or  insurers to submit such claims data in connection with the reimbursement requests as  he  deems  necessary  to  enable  him  to distribute  monies  and oversee the operation of the small employer stop loss fund. The superintendent may require that such data be submitted on a per member, aggregate and/or categorical basis.  (g) For the stop loss fund, the  superintendent  shall  calculate  the total   claims   reimbursement   amount   for   all  health  maintenance organizations, corporations or insurers for the calendar year for  which claims are being reported.  (1) In the event that the total amount requested for reimbursement for a calendar year exceeds funds available for distribution for claims paid during that same calendar year, the superintendent shall provide for the pro-rata  distribution  of  the available funds. Each health maintenance organization, corporation or insurer shall be eligible to  receive  only such  proportionate  amount  of  the  available  funds as the individual health maintenance  organization's,  corporation's  or  insurer's  total eligible  claims  paid  bears  to  the total eligible claims paid by all health maintenance organizations, corporations or insurers.  (2) In the event that funds available for distribution for claims paid by all health maintenance organizations, corporations or insurers during a calendar year exceeds the total amount requested for reimbursement  by  all  health  maintenance  organizations, corporations or insurers during that same calendar year, any excess funds shall be carried  forward  and made  available  for distribution in the next calendar year. Such excess funds  shall be in addition to the monies appropriated for the stop loss fund in the next calendar year.  (h) 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  small employer  stop  loss  fund.  Such  data  shall  be  furnished  in a form prescribed by the superintendent. Each health maintenance  organization, corporation  or  insurer  shall  provide the superintendent with monthly reports of the  total  enrollment  under  the  qualifying  group  health insurance  contracts  issued  pursuant  to  section  four thousand three hundred twenty-six of this article. The  reports  shall  be  in  a  form prescribed by the superintendent.  (i) The superintendent shall separately estimate the per member annual cost  of  total  claims  reimbursement  from  each  stop  loss  fund for qualifying group health insurance contracts based  upon  available  data and   appropriate  actuarial  assumptions.  Upon  request,  each  health maintenance organization, corporation or insurer shall  furnish  to  the superintendent claims experience data for use in such estimations.  (j) The superintendent shall determine total eligible enrollment under qualifying   group   health  insurance  contracts.  The  total  eligible enrollment shall be determined by dividing the total funds available for distribution from the small employer stop loss fund by the estimated per member annual cost of total claims reimbursement from the small employer stop loss fund.  (k) The superintendent shall suspend the enrollment of  new  employers under  qualifying group health insurance contracts if the superintendent determines that the total enrollment reported by all health  maintenance organizations, corporations or insurers under such contracts exceeds the total  eligible  enrollment,  thereby  resulting  in  anticipated annual expenditures from the small employer stop loss fund  in  excess  of  the total funds available for distribution from such stop loss fund.  (l)   The   superintendent   shall   provide  the  health  maintenance organizations,  corporations  or  insurers  with  notification  of   any enrollment  suspensions  as  soon  as  practicable  after receipt of all enrollment data.  (m) If  at  any  point  during  a  suspension  of  enrollment  of  new qualifying small employers, the superintendent determines that funds are sufficient   to  provide  for  the  addition  of  new  enrollments,  the superintendent shall be authorized to reactivate new enrollments and  to notify  all  health  maintenance organizations, corporations or insurers that enrollment of new employers may again commence.  (m-1) In the event that the superintendent suspends the enrollment  of new  individuals  for  qualifying  group health insurance contracts, the superintendent shall ensure that small employers seeking to enroll in  a qualified   group   health   insurance   contract  pursuant  to  section forty-three hundred twenty-six of this article are provided  information on and directed to coverage options available through the health benefit exchange established by this state.  (n)  The  suspension  of issuance of qualifying group health insurance contracts to new qualifying  small  employers  shall  not  preclude  the addition  of  new  employees of an employer already covered under such a contract or new dependents  of  employees  already  covered  under  such contracts.  (o)  The premiums for qualifying group health insurance contracts must factor in the availability of reimbursement from the small employer stop loss fund.  (p)  The  superintendent may obtain the services of an organization to administer  the  stop  loss  funds  established  by  this  section.  The superintendent   shall   establish  guidelines  for  the  submission  of proposals by organizations for the purposes of administering the  funds. The  superintendent  shall  make  a  determination  whether  to approve, disapprove or recommend modification to the proposal of an applicant  to administer  the  funds. An organization approved to administer the funds 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 funds, including 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 the  assembly  ways  and  means  committee.  An organization approved to administer the funds 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 stop  loss  coverage  funds.  An organization approved to administer the funds may be removed by the superintendent and  must  cooperate  in  the orderly  transition  of  services to another approved organization or to the superintendent.  (q)  If  the  superintendent  deems  it  appropriate  for  the  proper administration  of  the small employer 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   funds established by this section.  (r) The superintendent may access funding from the small employer stop loss  fund  for  the  purposes  of  developing  and  implementing public education, outreach and facilitated enrollment  strategies  targeted  to small   employers  without  health  insurance.  The  superintendent  may contract with marketing organizations to perform or  provide  assistance with   such   education,   outreach,   and  enrollment  strategies.  The superintendent shall determine the amount of funding available  for  the purposes of this subsection which in no event shall exceed eight percent of the annual funding amounts for the small employer stop loss fund.  (s)  Brooklyn  healthworks pilot program and upstate healthworks pilot program. Commencing on July first, two thousand six, the  superintendent shall  access  funding  from  the  small employer stop loss fund for the purpose of support and expansion of the existing pilot program  Brooklyn healthworks approved by the superintendent and for the establishment and operation  of a pilot program to be located in upstate New York. For the purpose of this subsection, in no event  shall  the  amount  of  funding available  exceed two percent of the annual funding amount for the small employer stop loss fund.