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 365.4 - Recoupment of costs of COVID-19 claims

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 365.4

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

(a) Notwithstanding any other provision of this Title, beginning plan year 2021 the superintendent may adjust premiums for family leave benefits in a manner necessary to enable the funding of the recoupment element of the COVID-19 Risk Adjustment Mechanism established by this Part.

(b) In exercising the power described in subsection (a) the superintendent shall:

(1)
(i) determine the actual total cost of COVID-19 claims paid by members of the COVID-19 Risk Adjustment Mechanism;

(ii) determine, in an exercise of discretion, a number of years over which recoupment will occur, provided, however, that such period shall not be greater than three years unless the superintendent separately determines that a longer period is necessary to avoid market disruption for family leave benefits; and

(iii) determine the estimated number of lives in the market in the plan year for which an adjustment is to be made; and

(2) adjust the premium for family leave benefits in an amount equal to the cost determined in subparagraph (i) of paragraph (1) of this subdivision divided by the number of years determined under subparagraph (ii) and the number of lives determined under subparagraph (iii) of that paragraph, actuarially converted to a percentage premium adjustment consistent with the manner in which family leave benefits premiums are set.

(c) In the event that the total COVID-19 claims are not available to the department prior to the date on which it approves the premium rate for family leave benefits for plan year 2021, the superintendent may use an actuarially appropriate estimate of the total COVID-19 claims that will be paid by members of the COVID-19 Risk Adjustment Mechanism in place of the actual claims for the purposes of subdivision (b) of this section.

(d) The superintendent may modify the adjustment each year to reflect changes in the factors considered, provided, however, that the superintendent shall not adjust the period over which recoupment will be run following plan year 2021 unless the superintendent separately determines a longer period is necessary to avoid disruption in the market.

(e) Notwithstanding any other rule, any adjustment made pursuant to this section shall not be included in the calculation of any commission to be paid by any insurer.

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