§ 4321-a. Fund for standardized individual enrollee direct payment\ncontracts.
(a)The superintendent shall establish a fund from which\nhealth maintenance organizations may receive reimbursement, to the\nextent of funds available therefor, for claims paid by such health\nmaintenance organizations for members covered under standardized\nindividual enrollee direct payment contracts issued pursuant to section\nfour thousand three hundred twenty-one of this article. The fund\nestablished by the superintendent pursuant to this section shall be\nknown as the direct payment stop loss fund. Commencing in calendar year\ntwo thousand, health maintenance organizations shall be eligible to\nreceive reimbursement from the direct payment stop loss fund for ninety\npercent of claims paid between twent
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§ 4321-a. Fund for standardized individual enrollee direct payment\ncontracts. (a) The superintendent shall establish a fund from which\nhealth maintenance organizations may receive reimbursement, to the\nextent of funds available therefor, for claims paid by such health\nmaintenance organizations for members covered under standardized\nindividual enrollee direct payment contracts issued pursuant to section\nfour thousand three hundred twenty-one of this article. The fund\nestablished by the superintendent pursuant to this section shall be\nknown as the direct payment stop loss fund. Commencing in calendar year\ntwo thousand, health maintenance organizations shall be eligible to\nreceive reimbursement from the direct payment stop loss fund for ninety\npercent of claims paid between twenty thousand and one hundred thousand\ndollars in a calendar year for any member covered under a contract\nissued pursuant to section four thousand three hundred twenty-one of\nthis article. For the purposes of this section, claims shall include\nhealth care claims paid by a health maintenance organization on behalf\nof a covered member pursuant to such standardized direct payment\ncontracts.\n (b) The superintendent shall promulgate regulations setting forth\nprocedures for the operation of the direct payment stop loss fund and\nthe distribution of monies therefrom.\n (c) Claims shall be reported and funds shall be distributed on a\ncalendar year basis. Claims shall be eligible for reimbursement only for\nthe calendar year in which the claims are paid. Once claims paid on\nbehalf of a member reach or exceed one hundred thousand dollars in a\ngiven calendar year, no further claims paid on behalf of such member in\nsuch calendar year shall be eligible for reimbursement.\n (d) Each health maintenance organization shall submit a request for\nreimbursement from the stop loss fund on a form prescribed by the\nsuperintendent. Such request for reimbursement shall be submitted no\nlater than April first following the end of the calendar year for which\nthe reimbursement request is being made. The superintendent may require\nhealth maintenance organizations to submit such claims data in\nconnection with the reimbursement request as he deems necessary to\nenable him to distribute monies and oversee the operation of the direct\npayment stop loss fund. The superintendent may require that such data be\nsubmitted on a per member, aggregate and/or categorical basis.\n (e) The superintendent shall calculate the total claims reimbursement\namount for all health maintenance organizations for the calendar year\nfor which claims are being reported.\n (1) In the event that the total amount requested for reimbursement by\nall health maintenance organizations for a calendar year exceeds funds\navailable for distribution for claims paid by all health maintenance\norganizations during that same calendar year, the superintendent shall\nprovide for the pro-rata distribution of the available funds. Each\nhealth maintenance organization shall be eligible to receive only such\nproportionate amount of the available funds as the individual health\nmaintenance organization's total eligible claims paid bears to the total\neligible claims paid by all health maintenance organizations.\n (2) In the event that (A) funds available for distribution for claims\npaid by all health maintenance organizations during a calendar year\nexceeds the total amount requested for reimbursement by all health\nmaintenance organizations during that same calendar year, and (B) the\ntotal amount requested for reimbursement by all health maintenance\norganizations from the direct payment out-of-plan stop loss fund exceeds\nthe amount available for distribution from such fund, then any excess\nfunds shall be reallocated for distribution to the direct payment\nout-of-plan stop loss fund. Otherwise, such excess funds shall be\ncarried forward and will not affect monies appropriated for the direct\npayment stop loss fund in the next calendar year.\n (f) Upon the request of the superintendent, each health maintenance\norganization shall be required to furnish such data as the\nsuperintendent deems necessary to oversee the operation of the direct\npayment stop loss fund. Such data shall be furnished in a form\nprescribed by the superintendent.\n (g) The superintendent may obtain the services of an organization to\nadminister the direct payment stop loss fund. The superintendent shall\nestablish guidelines for the submission of proposals by organizations\nfor the purposes of administering the fund. The superintendent shall\nmake a determination whether to approve, disapprove or recommend\nmodification to the proposal of an applicant to administer the fund. An\norganization approved to administer the fund shall submit reports to the\nsuperintendent in such form and at times as may be required by the\nsuperintendent in order to facilitate evaluation and ensure orderly\noperation of the fund, including, but not limited to an annual report of\nthe affairs and operations of the fund, such report to be delivered to\nthe superintendent and to the chairs of the senate finance committee and\nassembly ways and means committee. An organization approved to\nadminister the fund shall maintain records in a form prescribed by the\nsuperintendent and which shall be available for inspection by or at the\nrequest of the superintendent. The superintendent shall determine the\namount of compensation to be allocated to an approved organization as\npayment for fund administration. Compensation shall be payable from the\ndirect payment stop loss fund. An organization approved to administer\nthe fund may be removed by the superintendent and must cooperate in the\norderly transition of services to another approved organization or to\nthe superintendent.\n (h) If the superintendent deems it appropriate for the proper\nadministration of the direct payment stop loss fund, the administrator\nof the fund, on behalf of and with the prior approval of the\nsuperintendent, shall be authorized to purchase stop loss insurance\nand/or reinsurance from an insurance company licensed to write such type\nof insurance in this state. Such stop loss insurance and/or reinsurance\nmay be purchased to the extent of funds available therefor within such\nfunds which are available for purposes of the stop loss fund.\n