New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter XIV - Individual And Small Group Health Insurance
Part 365 - Paid Family Leave Covid- 19 Risk Adjustment Mechanism
Section 365.2 - Immediate relief payments from the COVID-19 Risk Adjustment Pool

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 365.2

Current through Register Vol. 46, No. 39, September 25, 2024

(a) Threshold to access immediate relief from the COVID-19 Risk Adjustment Pool.

(1) Any insurer with actual COVID-19 claims experience equal to or greater than 20 percent of the surplus of the insurer shall, pursuant to the requirements of this section, be eligible to apply for relief from the COVID-19 Risk Adjustment Pool.

(2) Relief from the COVID-19 Risk Adjustment Pool shall be granted only to the extent necessary to address losses suffered by the insurer as a result of COVID-19 claims. In no event shall relief be provided that exceeds the amount of the anticipated cost of COVID-19 claims as determined in the discretion of the superintendent.

(b) Content of the Application. Each written application for relief shall include statements affirmed as true under penalty of perjury by the chief executive officer as follows:

(1) the amount of the relief payment being requested;

(2) a statement that the insurer meets the threshold for relief pursuant to subdivision (a) of this section;

(3) a statement how the insurer intends to meet its requirement to pay an interest charge;

(4) a statement that relief funds will only be used to pay COVID-19 claims;

(5) instructions on the preferred manner of receiving relief funds if approved; and

(6) any other information the superintendent may require based on the facts and circumstances of a particular application.

(c) The superintendent shall review the application for relief and shall render a decision thereon, in the superintendent's sole discretion, within 15 business days of the date the application is deemed complete.

(d) If an application is approved, the superintendent shall set forth the decision in writing to the applicant. The decision will include the following:

(1) The approved amount of the relief;

(2) The interest rate that shall apply to the repayment and the manner in which the interest charge shall be paid; and

(3) Such conditions as the superintendent may determine necessary.

(e) In approving an amount of relief pursuant to this section, the superintendent shall consider COVID-19 claims which are anticipated to be paid by the insurer.

(f) If an application is denied, the superintendent shall set forth the reason for the denial. Denials are without prejudice for reapplication, however if three of more consecutive requests by an insurer have been denied, the superintendent may condition any reapplication for relief from that insurer on obtaining a report from an independent auditor certifying the need for relief.

(g) Approved relief shall be paid immediately from the COVID-19 Risk Adjustment Pool, subject to the availability of funds in the pool. If sufficient funds are not immediately available, the superintendent, in the superintendent's discretion, may cause a partial immediate payment to be made based on the availability of funds until funds are available in the COVID-19 Risk Adjustment Pool to pay the total approved relief outstanding.

(h) An insurer that has received relief pursuant this section shall not be eligible for further relief unless its actual COVID-19 claims, since the date of its previous application, are greater than the total amount of relief previously received at the time of its next application. The superintendent may authorize an earlier application if the circumstances warrant more rapid need.

(i) Special reporting requirement for insurers that receive immediate relief.

(1) Any insurer that received relief pursuant to this section shall submit a report by April 1, 2021 setting forth how such funds were utilized. The superintendent may make any investigation or require any special report or data reporting necessary to determine the use of funds received from the COVID-19 Risk Adjustment Pool.

(2) To the extent any funds received pursuant to this section were not utilized or were utilized for any purpose other than to pay COVID-19 claims, the superintendent may order the insurer to immediately repay any such amount to the COVID-19 Risk Adjustment Pool.

(j) The superintendent may require any insurer who receives an immediate relief payment under this section to make interest payments directly to the insurer or insurers, including the State Insurance Fund, whose contributions under section 365.3 of this Part funded the relief payment.

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