New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-5 - Rules Relating To The Direct Payment Market Stop Loss Relief Program And State Funded Stop Loss Relief For The Healthy New York Program › Section 362-5.2 - Eligibility of claims paid for reimbursement from the stop loss funds

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For each
				  contract eligible for reimbursement from a given stop loss fund, health
				  maintenance organizations and participating insurers shall record and aggregate
				  claims paid on a per member basis. Reimbursement from the applicable stop loss
				  fund shall be calculated based on such per member aggregates.
(b) Health maintenance organizations and
				  participating insurers shall be eligible for reimbursement of 90 percent of
				  claims paid within the applicable claims corridor on behalf of each member
				  covered under an individual enrollee direct payment contract, an individual
				  enrollee out- of-plan direct payment contract, a qualifying group health
				  insurance contract and a qualifying individual health insurance
				  contract.
(c) Health maintenance
				  organizations and participating insurers shall not be entitled to any
				  reimbursement on behalf of a covered member if the claims paid on behalf of
				  that member in a given calendar year do not, in the aggregate, reach the
				  applicable claims threshold. Additionally, claims paid on behalf of a covered
				  member which exceed the claims corridor in a given calendar year shall not be
				  eligible for reimbursement from the stop loss funds.
(d) Claims paid within a calendar year shall
				  be determined by the date of payment rather than the date of service or date
				  the claim was incurred. No health maintenance organization or participating
				  insurer shall delay or defer payment of a claim solely for the purpose of
				  causing the date of payment to fall into a subsequent calendar year.
(e) Claims paid shall not include interest
				  paid out by a health maintenance organization or participating insurer pursuant
				  to section 3224-a (c)  of the
				  Insurance Law.
(f) Claims paid
				  which are not submitted for reimbursement prior to April first of the calendar
				  year following the year in which they are paid shall not be eligible for
				  reimbursement from the stop loss funds and shall not be credited as paid claims
				  in any year for the purpose of determining whether the claims threshold has
				  been reached. If the superintendent determines that the claims data submitted
				  in conjunction with a reimbursement request is insufficient to make a
				  reimbursement determination, the superintendent or the stop loss fund
				  administrator shall make a request for clarification of the data or for the
				  submission of additional data. Health maintenance organizations and
				  participating insurers shall comply with all such requests within 15 business
				  days. If a health maintenance organization or participating insurer fails to
				  comply with such a request from the superintendent or the stop loss fund
				  administrator within 15 business days, the superintendent may in his discretion
				  deem any affected claims ineligible for reimbursement.
(g) For individual enrollee direct payment
				  contracts and individual enrollee out-of-plan direct payment contracts, claims
				  paid shall not include claims paid prior to January 1, 2000. For qualifying
				  group health insurance contracts and qualifying individual health insurance
				  contracts, claims paid shall not include claims paid prior to January 1,
				  2001.
(h) Claims paid shall include
				  capitation payments which can be directly attributed to securing the services
				  of a given provider or provider group on behalf of a member covered under an
				  individual enrollee direct payment contract or an individual enrollee
				  out-of-plan direct payment contract.
(i) Claims paid may include regional covered
				  lives assessments paid pursuant to section 2807-t  of the Public Health Law or
				  percentage surcharges paid pursuant to section 2807-j or section 2807-s  of the Public Health Law, but
				  shall not include amounts paid in satisfaction of 24 percent surcharge
				  requirement set forth in section 2807-j (2)(b)(i)(B)  of
				  the Public Health Law. Health maintenance organizations and participating
				  insurers which include the covered lives assessments shall convert the family
				  covered lives assessment into a per member assessment component in order to be
				  included with claims expenses attributable to any one member.
(j) If a health maintenance organization
				  writes the out-of-network portion of their individual enrollee out-of-plan
				  direct payment contract through an affiliate insurer, then the claims paid by
				  that insurer may be credited in determining whether the health maintenance
				  organization is eligible for reimbursement from the stop loss fund on behalf of
				  the covered member.