2023 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.