§ 4327. Stop loss funds for standardized health insurance contracts\nissued to qualifying small employers and qualifying individuals. (a) The\nsuperintendent shall establish a fund from which health maintenance\norganizations, corporations or insurers may receive reimbursement, to\nthe extent of funds available therefor, for claims paid by such health\nmaintenance organizations, corporations or insurers for members covered\nunder qualifying group health insurance contracts issued pursuant to\nsection four thousand three hundred twenty-six of this article. This\nfund shall be known as the "small employer stop loss fund".\n (b) Health maintenance organizations, corporations or insurers shall\nbe eligible to receive reimbursement for ninety percent of claims paid\nbetween five thousand and seventy-five thousand dollars in a calendar\nyear for any member covered under a standardized contract issued\npursuant to section four thousand three hundred twenty-six of this\narticle. Claims paid for members covered under qualifying group health\ninsurance contracts shall be reimbursable from the small employer stop\nloss fund. For the purposes of this section, claims shall include health\ncare claims paid by a health maintenance organization on behalf of a\ncovered member pursuant to such standardized contracts.\n (c) The superintendent shall promulgate regulations that set forth\nprocedures for the operation of the small employer stop loss fund and\ndistribution of monies therefrom.\n (d) The superintendent may adjust the level of stop loss coverage\nspecified in subsection (b) of this section.\n (e) Claims shall be reported and funds shall be distributed from the\nsmall employer stop loss fund on a calendar year basis. Claims shall be\neligible for reimbursement only for the calendar year in which the\nclaims are paid. Once claims paid on behalf of a covered member reach or\nexceed one hundred thousand dollars in a given calendar year, no further\nclaims paid on behalf of such member in that calendar year shall be\neligible for reimbursement.\n (f) Each health maintenance organization, corporation or insurer shall\nsubmit a request for reimbursement from the stop loss fund on forms\nprescribed by the superintendent. The requests for reimbursement shall\nbe submitted no later than April first following the end of the calendar\nyear for which the reimbursement requests are being made. The\nsuperintendent may require health maintenance organizations,\ncorporations or insurers to submit such claims data in connection with\nthe reimbursement requests as he deems necessary to enable him to\ndistribute monies and oversee the operation of the small employer stop\nloss fund. The superintendent may require that such data be submitted on\na per member, aggregate and/or categorical basis.\n (g) For the stop loss fund, the superintendent shall calculate the\ntotal claims reimbursement amount for all health maintenance\norganizations, corporations or insurers for the calendar year for which\nclaims are being reported.\n (1) In the event that the total amount requested for reimbursement for\na calendar year exceeds funds available for distribution for claims paid\nduring that same calendar year, the superintendent shall provide for the\npro-rata distribution of the available funds. Each health maintenance\norganization, corporation or insurer shall be eligible to receive only\nsuch proportionate amount of the available funds as the individual\nhealth maintenance organization's, corporation's or insurer's total\neligible claims paid bears to the total eligible claims paid by all\nhealth maintenance organizations, corporations or insurers.\n (2) In the event that funds available for distribution for claims paid\nby all health maintenance organizations, corporations or insurers during\na calendar year exceeds the total amount requested for reimbursement by\nall health maintenance organizations, corporations or insurers during\nthat same calendar y
‹ Prev All New York sections Next ›
Lexace provides legal information, not legal advice, and no attorney–client relationship is created. Statute text is provided for general information and may not reflect the most recent amendments; verify against the official state code.