New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter XIV - Individual And Small Group Health Insurance
Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program
Subpart 362-5 - Rules Relating To The Direct Payment Market Stop Loss Relief Program And State Funded Stop Loss Relief For The Healthy New York Program
Section 362-5.1 - Definitions applicable to the direct payment market stop loss relief program and state funded stop loss relief for the healthy new york program

(a) Capitation payments means contractually based prepayments made to a health care provider, on a per member per month or a percentage of premium basis, in exchange for health care services to be rendered, referred or otherwise arranged by such provider.

(b) Claims corridor means:

(c) Claims paid means claims paid by a health maintenance organization on behalf of a covered member pursuant to an individual enrollee direct payment contract issued pursuant to section 4321 of the Insurance Law or an individual enrollee out-of-plan direct payment contract issued pursuant to section 4322 of the Insurance Law. Claims paid shall also mean those claims paid by a health maintenance organization or participating insurer pursuant to a qualifying health insurance contract issued pursuant to section 4326 of the Insurance Law. Claims paid shall be determined by the date of payment rather than the date of service or date the claim was incurred.

(d) Claims threshold means the aggregate amount that a health maintenance organization or participating insurer must pay out as claims paid before reaching the applicable claims corridor and before becoming eligible for reimbursement on behalf of a covered member in a given calendar year.

(e) Direct payment out-of-plan stop loss fund means the fund established pursuant to section 4322-a (a) of the Insurance Law which is available to reimburse health maintenance organizations for certain claims paid during a calendar year on behalf of members covered under individual enrollee out-of-plan direct payment contracts issued pursuant to section 4322 of the Insurance Law.

(f) Direct payment stop loss fund means the fund established pursuant to section 4321-a (a) of the Insurance Law which is available to reimburse health maintenance organizations for certain claims paid during a calendar year on behalf of members covered under individual enrollee direct payment contracts issued pursuant to section 4321 of the Insurance Law.

(g) Health maintenance organization shall mean an organization (or line of business of an article 43 corporation) which has received a certificate of authority to operate as a health maintenance organization from the Commissioner of Health pursuant to article 44 of the Public Health Law, or, an article 43 corporation which is qualified within the meaning of section 1310(c) of title XIII of the Public Health Service Act.

(h) Individual enrollee direct payment contract means a contract written pursuant to section 4321 of the Insurance Law.

(i) Individual enrollee out-of-plan direct payment contract means a contract written pursuant to section 4322 of the Insurance Law.

(j) Qualifying individual stop loss fund means the fund established pursuant to section 4327 (a) of the Insurance Law which is available to reimburse health maintenance organizations and participating insurers for certain claims paid during a calendar year on behalf of members covered under a qualifying individual health insurance contract issued pursuant to section 4326 of the Insurance Law.

(k) Small employer stop loss fund means the fund established pursuant to section 4327 (a) of the Insurance Law which is available to reimburse health maintenance organizations for certain claims paid during a calendar year on behalf of members covered under a qualifying group health insurance contract issued pursuant to section 4326 of the Insurance Law.