Summary of Proposed Part 362 of Title 11 NYCRR:

The proposed regulation clarifies and defines various provisions of Chapter 1 of the Laws of 1999 in order to implement two programs, the Healthy New York Program and the Direct Payment Market Stop Loss Relief program.

Subpart 362-1 sets forth a preamble which restates the various public policy objectives of the Healthy New York Program and the Direct Payment Market Stop Loss Relief Program.

Subpart 362-2 sets forth provisions generally applicable to the Healthy New York Program.

Section 362-2.1 sets forth the definitions of terms which are generally applicable to the Healthy New York Program including the definition of health insurance, health maintenance organization, insurer, participating insurer, qualifying group health insurance contract, qualifying health insurance contract and qualifying individual health insurance contract.

Section 362-2.2 sets forth the terms of voluntary insurer participation in the Healthy New York program. Insurers wishing to offer qualifying group and individual health insurance contracts must submit a statement of intent to participate in the Healthy New York program in conjunction with the complete policy form and rate filings at least 90 days before the insurer intends to begin accepting applications. Insurers wishing to participate in the program must do so under the same terms and conditions as are applicable to health maintenance organizations.

Section 362-2.3 sets forth the procedures for enrolling in the Healthy New York Program. Applicants must make application and present eligibility certifications and supporting documentation directly to health maintenance organizations and participating insurers. Health maintenance organizations shall be responsible fo providing necessary information and enrollment forms and for examining eligibility certifications and supporting documentation for verification that applicants meet eligibility criteria. All applicants that meet eligibility criteria must be accepted to the Healthy New York program. Dependent children up to at least age 19 and full-time students up to at least age 23 shall be considered eligible dependents. In the event the superintendent suspends enrollment in the program, health maintenance organizations and participating insurers must continue to accept applications and maintain a waiting list.

Section 362-2.4 sets forth the circumstances under which an applicant enrolled in the New York State small business health insurance partnership program, the voucher insurance program, or the uninsured pilot programs may transfer into the Healthy New York Program without regard to certain otherwise applicable eligibility criteria.

Section 362-2.5 sets forth the requirements for annual re-certification of eligibility for participation in the Healthy New York Program. Health maintenance organizations and insurers are required to annually notify qualifying small employers and individuals of their responsibility to submit certifications of continued eligibility and necessary supporting documentation. The failure of an employer or individual to provide such materials are grounds for non-renewal of an insurance contract issued under the Healthy New York Program.

Subpart 362-3 sets forth rules relating to small employer (other than individual proprietors) participation in the Healthy New York program.

Section 362-3.1 sets forth the definitions applicable to small employers (other than individual proprietors) in the Healthy New York Program including the definition of employee and eligible employee.

Section 362-3.2 sets forth the conditions under which a small employer may participate in the Healthy New York Program. Small employers must have businesses located in New York State with fifty or fewer eligible employees, 30 percent of eligible employees must earn annual wages of $30,000 or less, 50 percent of eligible employees must participate in the program, coverage must be offered to all eligible employees earning less than $30,000 annually and at least one eligible employee earning $30,000 or less annually must participate. Qualifying small employers must contribute at least 50 percent of the premium for a group health insurance contract. Health maintenance organizations must collect and examine documentation verifying small employer eligibility. Contracts issued to small employers must have grace periods thirty days in length and must include conversion and continuation rights.

Subpart 362-4 sets forth rules relating to working uninsured individuals and individual proprietor participation in the Healthy New York program.

Section 362-4.1 sets forth the definitions of certain terms applicable to working uninsured individuals and individual proprietor participation in the Healthy New York Program including the definitions of employed person, episodic employment and individual proprietor.

Section 362-4.2 sets forth the conditions for working uninsured individuals and individual proprietor participation in the Healthy New York Program. Individuals who are eligible for health insurance under an employer-sponsored program in which the employer contributes toward the cost of the plan or premium are not eligible for participate in the Healthy New York Program. Subject to specified exceptions, working uninsured individuals or individual proprietors would not be eligible for participation in the Healthy New York program if they have coverage in place or have had access to employer provided coverage within the twelve month period preceding application. Working uninsured individuals and individual proprietors must be residents of New York State to participate. Health maintenance organizations must collect and examine documentation verifying small employer eligibility. Contracts issued to qualifying individuals and individual proprietors must have grace periods thirty days in length and must include conversion and continuation rights.

Section 362-4.3 sets forth the types of income that are counted in determining if a sole proprietor or working uninsured individual is eligible for the Healthy New York program and identifies some forms of documentation which may be relied upon to verify household income.

Subpart 362-5 sets forth rules relating to the Direct Payment Market Stop Loss Relief program and for state funded stop loss relief for the Healthy New York program.

Section 362-5.1 sets forth the definitions applicable to the Direct Payment Market Stop Loss Relief program and state funded stop loss relief for the Healthy New York program, including definitions of: capitation payments; claims corridor; claims paid; claims threshold; direct payment out-of-plan stop loss fund; direct payment stop loss fund; health maintenance organization; individual enrollee direct payment contract; individual enrollee out-of-plan direct payment contract; qualifying individual stop loss fund and small employer stop loss fund.

Section 362-5.2 sets forth the rules relating to eligibility of claims paid for reimbursement from the stop loss funds. Health maintenance organizations may be reimbursed for 90 percent of the claims paid in a calendar year within the applicable claims corridor on behalf of each member covered under an individual enrollee direct payment contract or an individual enrollee out-of-plan direct payment contract. Health maintenance organizations and participating insurers may be reimbursed for 90 percent of the claims paid in a calendar year within the applicable claims corridor on behalf of each member covered under qualifying health insurance contracts. Claims must be submitted for reimbursement on a timely basis in order to be eligible for payment. Capitation payments are reimburseable as paid claims for calendar year 2000 only.

Section 362-5.3 states that premiums for individual enrollee direct payment contrats, individual enrollee out-of-plan direct payment contracts and qualifying health insurance contracts must take into account the availability of reimbursement from the stop-loss fund. Reimbursement from the stop-loss funds shall reduce claims expenses for the purposes of calculating loss ratios, premium rates and premium rate adjustments and determining compliance with section 4308 of the Insurance Law and section 52.40 through section 52.45 of 11 NYCRR.

Section 362-5.4 identifies some of the functions of the superintendent with regard to administration of the stop-loss funds including selecting an administrator, collecting data from health maintenance organizations and insurers, and arranging for audits of health maintenance organizations and insurers.

Section 362-5.5 sets forth the data that health maintenance organizations and insurers must submit in order to obtain reimbursement from the stop loss funds and in connection with the administration of the Healthy New York Program. This data includes the total number of contracts issued within the reporting period, the total number of primary insureds, dependents covered and child dependents covered, premium, claims payment data, and data regarding claims eligible for reimbursement. Data must be reported separately for each stop loss fund. A coding system must be used to ensure privacy.