New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.5 - Pooling of variations in costs attributable to variations in specified medical conditions (SMC) beginning in 1999 through 2006

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In each pool area, a specified medical
				condition pool is established in connection with individual health insurance
				and small group health insurance policies, other than Medicare supplement
				insurance policies. Each pool area operates independently; that is, all
				calculations and payments described below are made for each pool independently
				of any other pool.
(b) The average
				relative cost factor is determined for each carrier participating in a pool,
				with respect to its participation in each pool separately, as follows:
(1) Assign the relative cost factor,
				according to Table 7 of this section, to each individual covered by a
				particular carrier under all pooled insurance contracts for policies in force
				on the date as of which the average relative cost factor is being calculated
				(the calculation date), which is the beginning of each six-month period
				starting January 1, 1999. The term
individual
shall mean each
				and every person covered under the subscriber contract or policy form
				including, but not limited to, a spouse, dependent children or other persons
				covered as a result of their relationship to the person to whom the subscriber
				contract or policy form was issued or the employee or other person issued a
				certificate of coverage by virtue of their membership within a group which has
				purchased coverage. If the carrier does not maintain records of the exact
				number of spouses, children and other persons covered under family coverage
				contracts then the carrier shall assume there are 2.3 persons covered in
				addition to the one employee, subscriber or policyholder. In such cases, data
				filed with the pool administrator must be accompanied by an attestation of
				either the carrier's chief financial officer or chief actuary that the carrier
				is unable to report accurate data concerning dependents.
(2) Each such individual who has had an
				eligible claim paid in the six-month period immediately preceding the
				calculation date for an ICD9 code listed on Table 7 of this section should be
				assigned the relative cost factor corresponding to the ICD9 code. Each
				individual will be assigned only one relative cost factor. If an individual has
				multiple conditions, assign the relative cost factor for the condition with the
				largest factor for the conditions pertaining to the individual. If an
				individual has had no claims paid for any of the ICD9 codes listed in Table 7,
				the relative cost factor for individuals without specified medical conditions
				should be assigned. For the claim(s) to be considered eligible the individual
				must have either had an overnight inpatient hospital stay or, for certain
				conditions, had total paid claims for the condition which together with paid
				claims for all other conditions exceed $5,000 in the six-month period. The
				certain conditions are AIDS/HIV, Asthma, Diabetes, Gaucher's Disease,
				Hemophilia, Lupus or Multiple sclerosis. These conditions are marked with an
				asterisk in Table 7.
(3) Determine
				the carrier's average relative cost factor by taking the sum of the relative
				cost factors for all individuals covered by the carrier and dividing that sum
				by the total number of individuals covered by the particular carrier under all
				pooled insurance contracts or policies in force as of the calculation
				date.