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 361.4 - Pooling of the cost of treating specified medical conditions prior to January 1, 1999

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 361.4

Current through Register Vol. 46, No. 12, March 20, 2024

(a) In each pool area, a specified medical condition pooling fund is established. Each pool operates independently; that is, all calculations and payments described below are made for each pool independently of any other pool.

(b) Each carrier shall pay to the pooling fund each quarter, beginning with the second quarter of 1993, and ending December 31, 1998, an amount determined as the product of paragraphs (1), (2), and (3) of this subdivision:

(1) An amount determined by the superintendent each year by September 1st, with respect to payments required during the subsequent calendar year. For 1993, this amount will be $5.

(2) The number of family units with coverage of a single individual under a pooled insurance contract or policy, other than a Medicare supplement insurance policy, as of the beginning of the quarter, plus twice the number of family units with dependents coverage by the carrier under a pooled insurance contract or policy, other than a Medicare supplement insurance policy, as of the beginning of the quarter.

(3) A coverage factor, as follows:

Type of Contract Coverage Factor
Basic Hospital or Basic Hospital/Surgical 0.75
Wraparound or Supplemental Major Medical 0.25
Basic and Supplemental Major Medical, Comprehensive Major Medical, HMO 1.0

(c) Each carrier may collect from the pooling fund in lump sum an amount listed in Table 1, subdivision (e) of this section, for claims incurred prior to January 1, 1997 and in lump sum an amount listed in Table 3, subdivision (e) of this section for claims incurred between January 1, 1997 and December 31, 1997 (but in no event more than the carrier is required to pay for the care of the listed medical condition), by submitting a claim in the calendar year following the calendar year in which the claim was incurred except that the deadline for filing 1997 claims is extended from December 31, 1998 to July 31, 2000, upon certification to the superintendent by the carrier that:

(1) an individual has been diagnosed as having one of the medical conditions listed in Table 1 or Table 3, subdivision (e) of this section as applicable, and the course of medical care identified in Table 1 or Table 3 has been recommended and completed;

(2) the identified individual is covered by the carrier under a pooled insurance contract or policy, other than a Medicare supplement insurance policy, for the identified medical care; and

(3) no other carrier or other third-party payor has primary responsibility for the cost of that medical care.

In the event that the individual changes carriers or is covered by more than one carrier under pooled insurance contracts or policies, other than a Medicare supplement insurance policy, during the course of the identified medical care, payment from the pooling fund of the amount listed in Table 1 or Table 3, subdivision (e) of this section, shall be pro-rated among the carriers based upon each carrier's proportionate share of the cost of the identified medical care. Insurers and HMOs may not base decisions as to whether a course of medical care is covered by an insurance or HMO policy or contract on the presence of that course of medical care in Table 1 or Table 3, subdivision (e) of this section, or the absence of that course of medical care from Table 1 or Table 3.

Distributions from the pooling fund of the amounts listed in Table 1 or Table 3, subdivision (e) of this section, shall be made based upon the month in which the claim attributable to expenses was incurred by the carrier. Older claims, based on the date the medical service was provided, will be given priority for payment over more recent claims.

(d) Each carrier may collect from the pooling fund each month an amount listed in Table 2, subdivision (e) of this section, for claims incurred prior to January 1, 1997 and each month an amount listed in Table 4, subdivision (e) of this section for claims incurred between January 1, 1997 and December 31, 1997, but in no event more than the carrier is required to pay for the care of the listed medical condition, by submitting a claim in the calendar year following the calendar year in which the claim was incurred except that the deadline for filing 1997 claims is extended from December 31, 1998 to July 31, 2000, upon certification to the superintendent by the carrier that:

(1) an individual has been diagnosed as having one of the medical conditions listed in Table 2 or Table 4, subdivision (e) of this section as applicable;

(2) the identified individual is covered by the carrier under a pooled insurance contract or policy, other than a Medicare supplement insurance policy, with respect to medical care for the identified medical condition as of the end of each month for which reimbursement is sought; and

(3) no other carrier or other third-party payor has primary responsibility for the cost of that medical care.

In the event that the individual is covered by more than one carrier under a pooled insurance contract or policy, other than a Medicare supplement insurance policy, payments from the pooling fund of the amount listed in Table 2 or Table 4, subdivision (e) of this section, shall be pro-rated among the carriers based upon each carrier's proportionate share of the cost of medical care for the identified medical condition.

Distributions from the pooling fund of the amounts listed in Table 2 or Table 4, subdivision (e) of this section, shall be made based upon the month in which the claim attributable to expenses was incurred by the carrier. Older claims, based on the date the medical service was provided, will be given priority for payment over more recent claims.

(e) Tables.

Table 1

Medical Condition Course of Medical Care Pool Payment
Irreversible, progressive liver disease Liver transplantation $ 80,000
Irreversible, progressive heart disease Heart transplantation 76,000
Irreversible, progressive pancreas disease Pancreas transplantation 56,000
Irreversible, progressive lung disease Pulmonary transplantation 136,000
Severe aplastic anemia Bone marrow transplantation 120,000
Acute leukemia Bone marrow transplantation 120,000
Chronic myelogenous leukemia (CML) in controlled (not blastic) phase Bone marrow transplantation 120,000
Neuroblastoma, Stage III or Stage IV in complete remission Bone marrow transplantation 120,000
Myelodysplastic syndrome Bone marrow transplantation 120,000
Hodgkins disease Bone marrow transplantation 120,000
Non-Hodgkins lymphoma Bone marrow transplantation 120,000
Severe combined immune deficiencies (SCID) Bone marrow transplantation 120,000
Wiskott-Aldrich Syndrome Bone marrow transplantation 120,000
Other condition, approved by the Superintendent in clinical situations where bone marrow transplantation has proven to be effective Bone marrow transplantation 120,000
Neonate with birth weight of less than 1500 grams ICU care for more than 30 days 96,000

Table 2

Medical Condition Monthly Payment
HIV disease where the CD4 count is below 50 on two consecutive tests $ 2,000
ALS leading to ventilator dependency for more than 30 days 13,000
Severe trauma leading to ventilator dependency for more than 30 days 13,000
Severe muscular dystrophy leading to ventilator dependency for more than 30 days 13,000

Table 3

Medical Condition or Criteria Course of Medical Care or Primary Diagnoses Maximum Pool Payment
AIDS ICD-9 code 042, 043, 044, 136.3, 117.5, 112.81 through 112.85, 176; or use of any of attached Drugs in Table 5 for treatment of AIDS $ 10,000
Irreversible, progressive liver disease Liver transplantation 80,000
Irreversible, progressive heart disease Heart transplantation 76,000
Irreversible, progressive pancreas disease Pancreas transplantation 56,000
Irreversible, progressive lung disease Pulmonary transplantation 136,000
Irreversible, progressive kidney disease Kidney transplantation not covered by Medicare 56,000
Medical necessity Bone marrow and stem cell procedures; CPT codes 38240 or 38241 120,000
Multiple Sclerosis ICD9 Code 340 plus use of medicines J1825 or J1830 7,500
Neonatal distress ICU care for more than 30 days 96,000
Gaucher's disease Use of medicines J0205, J1785 or NDC codes 58468178101, 58468106001 or 58468198301 75,000
Hemophilia with clotting factor VIII or IX ICD9 code 286.0, 286.1, 286.2, 286.4, 286.7 plus use of medicines J7190, J7191, J7129, J7194, or J7196; or treatment with drugs listed in Table 6 50,000

Table 4

Medical Condition Monthly Payment
ALS leading to ventilator dependency for more than 30 days $13,000
Severe trauma leading to ventilator dependency for more than 30 days 13,000
Severe muscular dystrophy leading to ventilator dependency for more than 30 days 13,000
Ventilator dependency with procedure code CPT 94657 of 30 units or more in given calendar year 13,000

Table 5

HIV/AIDS

FDB Label Name NDC Labeler Code NDC Product Code Manufacturer/ Package Size
COMBIVIR TABLET 00173 0595 00
COMBIVIR TABLET 00173 0595 02
CRIXIVAN 200 MG CAPSULE 00006 0571 42
CRIXIVAN 200 MG CAPSULE 00006 0571 43
CRIXIVAN 400 MG CAPSULE 00006 0573 54
CRIXIVAN 400 MG CAPSULE 00006 0573 62
EPIVIR 10MG/ML ORAL SOLN 00173 0471 00
EPIVIR 150MG TABLET 00173 0470 01
FORTOVASE 200MG SOFTGEL 00004 0246 48
HIVID 0.375MG TABLET 00004 0220 01
HIVID 0.75MG TABLET 00004 0221 01
INVIRASE 200MG CAPSULE 00004 0245 15
INVIRASE 200MG CAPSULE 54569 4242 01
NORVIR 100MG CAPSULE 00074 8492 02
NORVIR 100MG CAPSULE 00074 9492 54
NORVIR 100MG CAPSULE 54569 4335 00
NORVIR 100MG CAPSULE 54888 3782 00
NORVIR 80MG/ML SOLUTION 00074 1940 63
RESCRIPTOR 100MG TABLET 00009 3761 03
RETROVIR 100MG CAPSULE 00081 0108 56
RETROVIR 100MG CAPSULE 00173 0108 55
RETROVIR 100MG CAPSULE 00173 0108 56
RETROVIR 10MG/ML SYRUP 00173 0113 18
RETROVIR 300MG TABLET 00173 0501 00
VIDEX 100MG PACKET 00087 6614 43
VIDEX 100MG TABLET CHEWABLE 00087 6852 01
VIDEX 100MG TABLET CHEWABLE 00087 6627 43
VIDEX 150MG TABLET CHEWABLE 00087 6653 01
VIDEX 150MG TABLET CHEWABLE 00087 6626 43
VIDEX 157MG PACKET 00087 6616 43
VIDEX 250MG PACKET 00087 6616 43
VIDEX 25MG TABLET CHEWABLE 00087 6628 43
VIDEX 4GM PEDIATRIC SOLN 00087 6833 41
VIDEX 50MG TABLET CHEWABLE 00087 6651 01
VIDEX 50MG TABLET CHEWABLE 00087 6624 43
VIRACEPT 250MG TABLET 63010 0010 27
VIRACEPT POWDER 63010 0011 90
VIRAMUNE 200 MG TABLET 00054 4647 21
VIRAMUNE 200 MG TABLET 00054 4647 25
VIRAMUNE 200 MG TABLET 00054 8647 25
VIRAMUNE 200 MG TABLET 54868 3844 00
VIRAMUNE SUSP 50MG/5ML 00054 3905 58
ZERIT 20MG CAPSULE 00003 1965 01
ZERIT 30MG CAPSULE 00003 1968 01
ZERIT 30MG CAPSULE 54569 4053 00
ZERIT 40MG CAPSULE 00003 1967 01
SUSTIVA 50MG CAPSULE 00056 0470 30
SUSTIVA 100MG CAPSULE 00056 0473 30
SUSTIVA 200MG CAPSULE 00056 0474 92

Table 6

Factor VIII and IX NDC Codes

NDC Drug name Manufacturer
52769-0460-01 AntIhemop HU INJ 306-1170 AM RED CRO
13143-0321-63 Factor VIII inj 500-1200 MEL BIOLOG
00026-0664-30 KOATE-HP 500IU BAYER BIOL
00053-7605-02 HUMATE-P 500IU CENTEON
13143-0321-55 MELATE 500IU MEL BIOLOG
52789-0480-01 ANTIHEMOP HU ING 308-1170 AM RED CRO
00026-0664-50 KOATE-HP INJ 1000IU BAYER BIOL
00053-7605-04 HUMATE-P HU ING 1000IU CENTEON
00053-7656-04 MONOCLA-P HU INJ 1000IU CENTEON
13143-0321-56 MELATE 1000IU MEL BIOLOG
00026-0664-80 KOATE HP 1500IU BAYER BIOL
00053-7656-01 MONOCLA-P HU 250AHFU CENTEON
00063-7658-01 MONOCLATE 600AHFU ARMOUR
55688-0106-02 HYATE:C INJ 400-700U SPEYWOOD
00026-0670-20 KOGENATE 250 AHFU BAYER PHAR
00053-8110-01 BIOCLATE 250IU CENTEON
00053-8120-01 HELIXATE 260IU CENTEON
00944-2938-01 RECOMBINATE 220-400 BAXHYLAND
00026-0670-30 KOGENATE 500AHFU BAYER BIOL
00053-8110-02 BIOCLATE 500IU CENTEON
00053-8120-02 HELIXATE 500IU CENTEON
00944-2938-02 RECOMBINATE 401-800 BAXHYLAND
00026-0670-30 KOGENATE 500AHFU BAYER BIOL
00053-8110-02 BIOCLATE 600IU CENTEON
00053-8120-02 HELIXATE 500IU CENTEON
00944-2938-02 RECOMBINATE 401-800 BAXHYLAND
00028-0670-50 KOGENATE 1000AHFU BAYER BIOL
00053-8110-04 BIOCLATE 1000IU CENTEON
00944-2938-03 RECOMBINATE 801-1240 BAXHYLAND
49889-3800-02 ALPHANINE SD 250-1600 ALPHA THER
00053-7668-01 MONONINE 250IU CENTEON
00053-7668-02 MONONINE 500IU CENTEON
00053-7668-04 MONONINE 1000IU CENTEON
58394-0003-01 BENEFIX 250IU GENETICSIN
58394-0002-01 BENEFIX 500IU GENETICSIN
58394-0001-01 BENEFIX 1000IU GENETICSIN
00026-0626-20 KONYNE 80 500IU BAYER BIOL
00944-0581-01 PROPLEX T FACT IX BAXHYLAND
49669-3200-02 PROFILNILE 500IU ALPHA THER
00026-0626-50 KONYNE 80 1000IU BAYER BIOL
49689-3200-03 PROFILNILE 1000IU ALPHA THER
54129-0244-02 BEBULIN VH 200-1200 IMMUNO

(f) The pooling of the cost of treating specified medical conditions for claims incurred in 1998 shall occur as follows:

(1) Separately for each carrier, add the dollar amounts shown in Table 3, subdivision (e) of this section for each individual specified medical condition claim incurred during 1998 and listed in Table 3 and six times the dollar amounts shown in Table 4, subdivision (e) of this section for each individual specified medical condition claim incurred during 1998 and listed in Table 4. No individual can be counted more than once. If an individual has multiple conditions, assign to such individual the condition with the largest dollar amount. This total shall be the carrier's own total maximum specified medical condition claims.

(2) Separately for each carrier, the total maximum specified medical condition claims from paragraph (1) of this subdivision shall be divided by that carrier's 1998 contributions to the specified medical condition pool (as required by subdivision [b] of this section) to obtain that carrier's specified medical condition index.

(3) The regional specified medical condition index for all carriers in a specific region shall be subparagraph (i) divided by subparagraph (ii) of this paragraph:
(i) The sum for all carriers in the region of the total maximum specified medical condition claims as determined in paragraph (1) of this subdivision.

(ii) The sum for all carriers in the region of the 1998 contributions to the specified medical condition pool in that region.

(4) The carriers participating in the regional specified medical condition pool shall only be entitled to collect from the pool if the carrier's own specified medical condition index, determined by paragraph (2) of this subdivision, is greater than the regional specified medical condition index, determined by paragraph (3) of this subdivision, for that pool as of the end of 1998. Individual specified medical condition claims will no longer be reimbursed by the pool in 1998.

(5) A carrier entitled to collect from the 1998 specified medical condition pooling fund as determined by paragraph (4) of this subdivision may collect the product of subparagraphs (i) and (ii) of this paragraph:
(i) That carrier's percentage of the specified medical condition funds, determined by dividing clause (a) by clause (b) of this subparagraph:
(a) the amount by which the carrier's specified medical condition index is greater than the regional specified medical condition index weighted by the carrier's own 1998 specified medical condition contributions to the regional pool (determined by subtracting the regional specified medical condition index from the specified medical condition index for that carrier and then multiplying the result of the subtraction by the carrier's own 1998 specified medical condition contributions to the regional pool);

(b) the sum of the amounts determined in clause (a) of this subparagraph for all carriers in the regional pool who are entitled to collect from the 1998 specified medical condition pooling fund.

(ii) The sum of the 1998 specified medical condition funds available for distribution in that region plus the amount of funds for 1998 representing the 55 percent reduction in demographic payments in that region to pools that deal with individual health insurance policies and small group health insurance policies, other than Medicare supplement insurance policies.

(6) A carrier shall only be entitled to collect from the 1998 specified medical condition pooling fund an amount calculated pursuant to the method established in paragraphs (4) and (5) of this subdivision upon certification to the superintendent by the carrier by no later than July 31, 2000, that with respect to the claims reported to the administrator and used in paragraph (1) of this subdivision that:
(i) regarding the medical conditions listed in Table 3, subdivision (e) of this section:
(a) an individual has been diagnosed as having one of the medical conditions or criteria listed in Table 3, subdivision (e) of this section, and the course of medical care identified in Table 3 has been recommended and completed;

(b) the identified individual is covered by the carrier under a pooled insurance contract or policy, other than a Medicare supplement insurance policy, for the identified medical care; and

(c) no other carrier or other third-party payor has primary responsibility for the cost of that medical care;

(ii) regarding the medical conditions listed in Table 4, subdivision (e) of this section:
(a) an individual has been diagnosed as having one of the medical conditions listed in Table 4, subdivision (e) of this section;

(b) the identified individual is covered by the carrier under a pooled insurance contract or policy, other than a Medicare supplement insurance policy, with respect to medical care for the identified medical condition as of the end of each month for which reimbursement is sought; and

(c) no other carrier or other third-party payor has primary responsibility for the cost of that medical care.

(g) A carrier must report the number of claims that have been incurred for 1998 separately for each category listed in Table 3, subdivision (e) of this section and Table 4, subdivision (e) of this section in a manner prescribed by the superintendent.

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