* § 4327. Stop loss funds for standardized health insurance contracts\nissued to qualifying small employers and qualifying individuals. (a) The\nsuperintendent shall establish a fund from which health maintenance\norganizations, corporations or insurers may receive reimbursement, to\nthe extent of funds available therefor, for claims paid by such health\nmaintenance organizations, corporations or insurers for members covered\nunder qualifying group health insurance contracts issued pursuant to\nsection four thousand three hundred twenty-six of this article. This\nfund shall be known as the "small employer stop loss fund". The\nsuperintendent shall establish a separate and distinct fund from which\nhealth maintenance organizations, corporations or insurers may receive\nreimbursement, to the extent of funds available therefor, for claims\npaid by such health maintenance organizations, corporations or insurers\nfor members covered under qualifying individual health insurance\ncontracts issued pursuant to section four thousand three hundred\ntwenty-six of this article. This fund shall be known as the "qualifying\nindividual stop loss fund".\n (b) Commencing on January first, two thousand one, health maintenance\norganizations, corporations or insurers shall be eligible to receive\nreimbursement for ninety percent of claims paid between thirty thousand\nand one hundred thousand dollars in a calendar year for any member\ncovered under a standardized contract issued pursuant to section four\nthousand three hundred twenty-six of this article. Claims paid for\nmembers covered under qualifying group health insurance contracts shall\nbe reimbursable from the small employer stop loss fund. Claims paid for\nmembers covered under qualifying individual health insurance contracts\nshall be reimbursable from the qualifying individual stop loss fund. For\nthe purposes of this section, claims shall include health care claims\npaid by a health maintenance organization on behalf of a covered member\npursuant to such standardized contracts.\n (c) The superintendent shall promulgate regulations that set forth\nprocedures for the operation of the small employer stop loss fund and\nthe qualifying individual stop loss fund and distribution of monies\ntherefrom.\n (d) The small employer stop loss fund shall operate separately from\nthe qualifying individual stop loss fund. Except as specified in\nsubsection (b) of this section with respect to calendar year two\nthousand one, the level of stop loss coverage for the qualifying group\nhealth insurance contracts and the qualifying individual health\ninsurance contracts need not be the same. The two stop loss funds need\nnot be structured or operated in the same manner, except as specified in\nthis section. The monies available for distribution from the stop loss\nfunds may be reallocated between the small employer stop loss fund and\nthe qualifying individual stop loss fund if the superintendent\ndetermines that such reallocation is warranted due to enrollment trends.\n (e) Claims shall be reported and funds shall be distributed from the\nsmall employer stop loss fund and from the qualifying individual stop\nloss fund on a calendar year basis. Claims shall be eligible for\nreimbursement only for the calendar year in which the claims are paid.\nOnce claims paid on behalf of a covered member reach or exceed one\nhundred thousand dollars in a given calendar year, no further claims\npaid on behalf of such member in that calendar year shall be eligible\nfor reimbursement.\n (f) Each health maintenance organization, corporation or insurer shall\nsubmit a request for reimbursement from each of the stop loss funds on\nforms prescribed by the superintendent. Each of the requests for\nreimbursement shall be submitted no later than April first following the\nend of the calendar year for which the reimbursement requests are being\nmade. The superintendent may require health maintenance organizations,\ncorporations or insurers to submit such claims data in connection with\nthe reimbursement requests as he deems necessary to enable him to\ndistribute monies and oversee the operation of the small employer and\nqualifying individual stop loss funds. The superintendent may require\nthat such data be submitted on a per member, aggregate and/or\ncategorical basis. Data shall be reported separately for qualifying\ngroup health insurance contracts and qualifying individual health\ninsurance contracts issued pursuant to section four thousand three\nhundred twenty-six of this article.\n (g) For each stop loss fund, the superintendent shall calculate the\ntotal claims reimbursement amount for all health maintenance\norganizations, corporations or insurers for the calendar year for which\nclaims are being reported.\n (1) In the event that the total amount requested for reimbursement for\na calendar year exceeds funds available for distribution for claims paid\nduring that same calendar year, the superintendent shall provide for the\npro-rata distribution of the available funds. Each health maintenance\norganization, corporation or insurer shall be eligible to receive only\nsuch proportionate amount of the available funds as the individual\nhealth maintenance organization's, corporation's or insurer's total\neligible claims paid bears to the total eligible claims paid by all\nhealth maintenance organizations, corporations or insurers.\n (2) In the event that funds available for distribution for claims paid\nby all health maintenance organizations, corporations or insurers during\na calendar year exceeds the total amount requested for reimbursement by\nall health maintenance organizations, corporations or insurers during\nthat same calendar year, any excess funds shall be carried forward and\nmade available for distribution in the next calendar year. Such excess\nfunds shall be in addition to the monies appropriated for the stop loss\nfund in the next calendar year.\n (h) Upon the request of the superintendent, each health maintenance\norganization shall be required to furnish such data as the\nsuperintendent deems necessary to oversee the operation of the small\nemployer and qualifying individual stop loss funds. Such data shall be\nfurnished in a form prescribed by the superintendent. Each health\nmaintenance organization, corporation or insurer shall provide the\nsuperintendent with monthly reports of the total enrollment under the\nqualifying group health insurance contracts and the qualifying\nindividual health insurance contracts issued pursuant to section four\nthousand three hundred twenty-six of this article. The reports shall be\nin a form prescribed by the superintendent.\n (i) The superintendent shall separately estimate the per member annual\ncost of total claims reimbursement from each stop loss fund for\nqualifying individual health insurance contracts and for qualifying\ngroup health insurance contracts based upon available data and\nappropriate actuarial assumptions. Upon request, each health maintenance\norganization, corporation or insurer shall furnish to the superintendent\nclaims experience data for use in such estimations.\n (j) The superintendent shall determine total eligible enrollment under\nqualifying group health insurance contracts and qualifying individual\nhealth insurance contracts. For qualifying group health insurance\ncontracts, the total eligible enrollment shall be determined by dividing\nthe total funds available for distribution from the small employer stop\nloss fund by the estimated per member annual cost of total claims\nreimbursement from the small employer stop loss fund. For qualifying\nindividual health insurance contracts, the total eligible enrollment\nshall be determined by dividing the total funds available for\ndistribution from the qualifying individual stop loss fund by the\nestimated per member annual cost of total claims reimbursement from the\nqualifying individual stop loss fund.\n (k) The superintendent shall suspend the enrollment of new employers\nunder qualifying group health insurance contracts if he determines that\nthe total enrollment reported by all health maintenance organizations,\ncorporations or insurers under such contracts exceeds the total eligible\nenrollment, thereby resulting in anticipated annual expenditures from\nthe small employer stop loss fund in excess of the total funds available\nfor distribution from such stop loss fund. The superintendent shall\nsuspend the enrollment of new individuals under qualifying individual\nhealth insurance contracts if he determines that the total enrollment\nreported by all health maintenance organizations, corporations or\ninsurers under such contracts exceeds the total eligible enrollment,\nthereby resulting in anticipated annual expenditures from the qualifying\nindividual stop loss fund in excess of the total funds available for\ndistribution from such stop loss fund.\n (l) The superintendent shall provide the health maintenance\norganizations, corporations or insurers with notification of any\nenrollment suspensions as soon as practicable after receipt of all\nenrollment data. The superintendent's determination and notification\nshall be made separately for the qualifying group health insurance\ncontracts and for the qualifying individual health insurance contracts.\n (m) If at any point during a suspension of enrollment of new\nqualifying small employers and/or qualifying individuals, the\nsuperintendent determines that funds are sufficient to provide for the\naddition of new enrollments, the superintendent shall be authorized to\nreactivate new enrollments and to notify all health maintenance\norganizations, corporations or insurers that enrollment of new employers\nand/or individuals may again commence. The superintendent's\ndetermination and notification shall be made separately for the\nqualifying group health insurance contracts and for the qualifying\nindividual health insurance contracts.\n (m-1) In the event that the superintendent suspends the enrollment of\nnew individuals for qualifying group health insurance contracts or\nqualifying individual health insurance contracts, the superintendent\nshall ensure that small employers or sole proprietors seeking to enroll\nin a qualified group or individual health insurance contract pursuant to\nsection forty-three hundred twenty-six of this article are provided\ninformation on and directed to the family health plus employer\npartnership program under section three hundred sixty-nine-ff of the\nsocial services law.\n (n) The suspension of issuance of qualifying group health insurance\ncontracts to new qualifying small employers shall not preclude the\naddition of new employees of an employer already covered under such a\ncontract or new dependents of employees already covered under such\ncontracts.\n (o) The suspension of issuance of qualifying individual health\ninsurance contracts to new qualifying individuals shall not preclude the\naddition of new dependents to an existing qualifying individual health\ninsurance contract.\n (p) The premiums for qualifying group health insurance contracts must\nfactor in the availability of reimbursement from the small employer stop\nloss fund. The premiums for qualifying individual health insurance\ncontracts must factor in the availability of reimbursement from the\nqualifying individual stop loss funds.\n (q) The superintendent may obtain the services of an organization to\nadminister the stop loss funds established by this section. If the\nsuperintendent deems it appropriate, he or she may utilize a separate\norganization for administration of the small employer stop loss fund and\nthe qualifying individual stop loss fund. The superintendent shall\nestablish guidelines for the submission of proposals by organizations\nfor the purposes of administering the funds. The superintendent shall\nmake a determination whether to approve, disapprove or recommend\nmodification to the proposal of an applicant to administer the funds. An\norganization approved to administer the funds shall submit reports to\nthe superintendent in such form and at times as may be required by the\nsuperintendent in order to facilitate evaluation and ensure orderly\noperation of the funds, including, but not limited to, an annual report\nof the affairs and operations of the fund, such report to be delivered\nto the superintendent and to the chairs of the senate finance committee\nand the assembly ways and means committee. An organization approved to\nadminister the funds shall maintain records in a form prescribed by the\nsuperintendent and which shall be available for inspection by or at the\nrequest of the superintendent. The superintendent shall determine the\namount of compensation to be allocated to an approved organization as\npayment for fund administration. Compensation shall be payable from the\nstop loss coverage funds. An organization approved to administer the\nfunds may be removed by the superintendent and must cooperate in the\norderly transition of services to another approved organization or to\nthe superintendent.\n (r) If the superintendent deems it appropriate for the proper\nadministration of the small employer stop loss fund and/or the\nqualifying individual stop loss fund, the administrator of the fund, on\nbehalf of and with the prior approval of the superintendent, shall be\nauthorized to purchase stop loss insurance and/or reinsurance from an\ninsurance company licensed to write such type of insurance in this\nstate. Such stop loss insurance and/or reinsurance may be purchased to\nthe extent of funds available therefor within such funds which are\navailable for purposes of the stop loss funds established by this\nsection.\n (s) The superintendent may access funding from the small employer stop\nloss fund and/or the qualifying individual stop loss fund for the\npurposes of developing and implementing public education, outreach and\nfacilitated enrollment strategies targeted to small employers and\nworking adults without health insurance. The superintendent may contract\nwith marketing organizations to perform or provide assistance with such\neducation, outreach, and enrollment strategies. The superintendent shall\ndetermine the amount of funding available for the purposes of this\nsubsection which in no event shall exceed eight percent of the annual\nfunding amounts for the small employer stop loss fund and the qualifying\nindividual stop loss fund.\n (t) Brooklyn healthworks pilot program and upstate healthworks pilot\nprogram. Commencing on July first, two thousand six, the superintendent\nshall access funding from the small employer stop loss fund and the\nqualifying individual stop loss fund for the purpose of support and\nexpansion of the existing pilot program Brooklyn healthworks approved by\nthe superintendent and for the establishment and operation of a pilot\nprogram to be located in upstate New York. For the purpose of this\nsubsection, in no event shall the amount of funding available exceed two\npercent of the annual funding amounts for the small employer stop loss\nfund and the qualifying individual stop loss fund.\n * NB Effective until January 1, 2015\n * § 4327. Stop loss funds for standardized health insurance contracts\nissued to qualifying small employers and qualifying individuals. (a) The\nsuperintendent shall establish a fund from which health maintenance\norganizations, corporations or insurers may receive reimbursement, to\nthe extent of funds available therefor, for claims paid by such health\nmaintenance organizations, corporations or insurers for members covered\nunder qualifying group health insurance contracts issued pursuant to\nsection four thousand three hundred twenty-six of this article. This\nfund shall be known as the "small employer stop loss fund".\n (b) Health maintenance organizations, corporations or insurers shall\nbe eligible to receive reimbursement for ninety percent of claims paid\nbetween five thousand and seventy-five thousand dollars in a calendar\nyear for any member covered under a standardized contract issued\npursuant to section four thousand three hundred twenty-six of this\narticle. Claims paid for members covered under qualifying group health\ninsurance contracts shall be reimbursable from the small employer stop\nloss fund. For the purposes of this section, claims shall include health\ncare claims paid by a health maintenance organization on behalf of a\ncovered member pursuant to such standardized contracts.\n (c) The superintendent shall promulgate regulations that set forth\nprocedures for the operation of the small employer stop loss fund and\ndistribution of monies therefrom.\n (d) The superintendent may adjust the level of stop loss coverage\nspecified in subsection (b) of this section.\n (e) Claims shall be reported and funds shall be distributed from the\nsmall employer stop loss fund on a calendar year basis. Claims shall be\neligible for reimbursement only for the calendar year in which the\nclaims are paid. Once claims paid on behalf of a covered member reach or\nexceed one hundred thousand dollars in a given calendar year, no further\nclaims paid on behalf of such member in that calendar year shall be\neligible for reimbursement.\n (f) Each health maintenance organization, corporation or insurer shall\nsubmit a request for reimbursement from the stop loss fund on forms\nprescribed by the superintendent. The requests for reimbursement shall\nbe submitted no later than April first following the end of the calendar\nyear for which the reimbursement requests are being made. The\nsuperintendent may require health maintenance organizations,\ncorporations or insurers to submit such claims data in connection with\nthe reimbursement requests as he deems necessary to enable him to\ndistribute monies and oversee the operation of the small employer stop\nloss fund. The superintendent may require that such data be submitted on\na per member, aggregate and/or categorical basis.\n (g) For the stop loss fund, the superintendent shall calculate the\ntotal claims reimbursement amount for all health maintenance\norganizations, corporations or insurers for the calendar year for which\nclaims are being reported.\n (1) In the event that the total amount requested for reimbursement for\na calendar year exceeds funds available for distribution for claims paid\nduring that same calendar year, the superintendent shall provide for the\npro-rata distribution of the available funds. Each health maintenance\norganization, corporation or insurer shall be eligible to receive only\nsuch proportionate amount of the available funds as the individual\nhealth maintenance organization's, corporation's or insurer's total\neligible claims paid bears to the total eligible claims paid by all\nhealth maintenance organizations, corporations or insurers.\n (2) In the event that funds available for distribution for claims paid\nby all health maintenance organizations, corporations or insurers during\na calendar year exceeds the total amount requested for reimbursement by\nall health maintenance organizations, corporations or insurers during\nthat same calendar year, any excess funds shall be carried forward and\nmade available for distribution in the next calendar year. Such excess\nfunds shall be in addition to the monies appropriated for the stop loss\nfund in the next calendar year.\n (h) Upon the request of the superintendent, each health maintenance\norganization shall be required to furnish such data as the\nsuperintendent deems necessary to oversee the operation of the small\nemployer stop loss fund. Such data shall be furnished in a form\nprescribed by the superintendent. Each health maintenance organization,\ncorporation or insurer shall provide the superintendent with monthly\nreports of the total enrollment under the qualifying group health\ninsurance contracts issued pursuant to section four thousand three\nhundred twenty-six of this article. The reports shall be in a form\nprescribed by the superintendent.\n (i) The superintendent shall separately estimate the per member annual\ncost of total claims reimbursement from each stop loss fund for\nqualifying group health insurance contracts based upon available data\nand appropriate actuarial assumptions. Upon request, each health\nmaintenance organization, corporation or insurer shall furnish to the\nsuperintendent claims experience data for use in such estimations.\n (j) The superintendent shall determine total eligible enrollment under\nqualifying group health insurance contracts. The total eligible\nenrollment shall be determined by dividing the total funds available for\ndistribution from the small employer stop loss fund by the estimated per\nmember annual cost of total claims reimbursement from the small employer\nstop loss fund.\n (k) The superintendent shall suspend the enrollment of new employers\nunder qualifying group health insurance contracts if the superintendent\ndetermines that the total enrollment reported by all health maintenance\norganizations, corporations or insurers under such contracts exceeds the\ntotal eligible enrollment, thereby resulting in anticipated annual\nexpenditures from the small employer stop loss fund in excess of the\ntotal funds available for distribution from such stop loss fund.\n (l) The superintendent shall provide the health maintenance\norganizations, corporations or insurers with notification of any\nenrollment suspensions as soon as practicable after receipt of all\nenrollment data.\n (m) If at any point during a suspension of enrollment of new\nqualifying small employers, the superintendent determines that funds are\nsufficient to provide for the addition of new enrollments, the\nsuperintendent shall be authorized to reactivate new enrollments and to\nnotify all health maintenance organizations, corporations or insurers\nthat enrollment of new employers may again commence.\n (m-1) In the event that the superintendent suspends the enrollment of\nnew individuals for qualifying group health insurance contracts, the\nsuperintendent shall ensure that small employers seeking to enroll in a\nqualified group health insurance contract pursuant to section\nforty-three hundred twenty-six of this article are provided information\non and directed to coverage options available through the health benefit\nexchange established pursuant to section 1311 of the affordable care\nact, 42 U.S.C. § 18031.\n (n) The suspension of issuance of qualifying group health insurance\ncontracts to new qualifying small employers shall not preclude the\naddition of new employees of an employer already covered under such a\ncontract or new dependents of employees already covered under such\ncontracts.\n (o) The premiums for qualifying group health insurance contracts must\nfactor in the availability of reimbursement from the small employer stop\nloss fund.\n (p) The superintendent may obtain the services of an organization to\nadminister the stop loss funds established by this section. The\nsuperintendent shall establish guidelines for the submission of\nproposals by organizations for the purposes of administering the funds.\nThe superintendent shall make a determination whether to approve,\ndisapprove or recommend modification to the proposal of an applicant to\nadminister the funds. An organization approved to administer the funds\nshall submit reports to the superintendent in such form and at times as\nmay be required by the superintendent in order to facilitate evaluation\nand ensure orderly operation of the funds, including an annual report of\nthe affairs and operations of the fund, such report to be delivered to\nthe superintendent and to the chairs of the senate finance committee and\nthe assembly ways and means committee. An organization approved to\nadminister the funds shall maintain records in a form prescribed by the\nsuperintendent and which shall be available for inspection by or at the\nrequest of the superintendent. The superintendent shall determine the\namount of compensation to be allocated to an approved organization as\npayment for fund administration. Compensation shall be payable from the\nstop loss coverage funds. An organization approved to administer the\nfunds may be removed by the superintendent and must cooperate in the\norderly transition of services to another approved organization or to\nthe superintendent.\n (q) If the superintendent deems it appropriate for the proper\nadministration of the small employer stop loss fund, the administrator\nof the fund, on behalf of and with the prior approval of the\nsuperintendent, shall be authorized to purchase stop loss insurance\nand/or reinsurance from an insurance company licensed to write such type\nof insurance in this state. Such stop loss insurance and/or reinsurance\nmay be purchased to the extent of funds available therefor within such\nfunds which are available for purposes of the stop loss funds\nestablished by this section.\n (r) The superintendent may access funding from the small employer stop\nloss fund for the purposes of developing and implementing public\neducation, outreach and facilitated enrollment strategies targeted to\nsmall employers without health insurance. The superintendent may\ncontract with marketing organizations to perform or provide assistance\nwith such education, outreach, and enrollment strategies. The\nsuperintendent shall determine the amount of funding available for the\npurposes of this subsection which in no event shall exceed eight percent\nof the annual funding amounts for the small employer stop loss fund.\n (s) Brooklyn healthworks pilot program and upstate healthworks pilot\nprogram. Commencing on July first, two thousand six, the superintendent\nshall access funding from the small employer stop loss fund for the\npurpose of support and expansion of the existing pilot program Brooklyn\nhealthworks approved by the superintendent and for the establishment and\noperation of a pilot program to be located in upstate New York. For the\npurpose of this subsection, in no event shall the amount of funding\navailable exceed two percent of the annual funding amount for the small\nemployer stop loss fund.\n * NB Effective January 1, 2015\n
§ 4327. Stop loss funds for standardized health insurance contracts\nissued to qualifying small employers and qualifying individuals. (a) The\nsuperintendent shall establish a fund from which health maintenance\norganizations, corporations or insurers may receive reimbursement, to\nthe extent of funds available therefor, for claims paid by such health\nmaintenance organizations, corporations or insurers for members covered\nunder qualifying group health insurance contracts issued pursuant to\nsection four thousand three hundred twenty-six of this article. This\nfund shall be known as the "small employer stop loss fund".\n (b) Health maintenance organizations, corporations or insurers shall\nbe eligible to receive reimbursement for ninety percent of claims paid\nbetween five thousand and seventy-five thousand dollars in a calendar\nyear for any member covered under a standardized contract issued\npursuant to section four thousand three hundred twenty-six of this\narticle. Claims paid for members covered under qualifying group health\ninsurance contracts shall be reimbursable from the small employer stop\nloss fund. For the purposes of this section, claims shall include health\ncare claims paid by a health maintenance organization on behalf of a\ncovered member pursuant to such standardized contracts.\n (c) The superintendent shall promulgate regulations that set forth\nprocedures for the operation of the small employer stop loss fund and\ndistribution of monies therefrom.\n (d) The superintendent may adjust the level of stop loss coverage\nspecified in subsection (b) of this section.\n (e) Claims shall be reported and funds shall be distributed from the\nsmall employer stop loss fund on a calendar year basis. Claims shall be\neligible for reimbursement only for the calendar year in which the\nclaims are paid. Once claims paid on behalf of a covered member reach or\nexceed one hundred thousand dollars in a given calendar year, no further\nclaims paid on behalf of such member in that calendar year shall be\neligible for reimbursement.\n (f) Each health maintenance organization, corporation or insurer shall\nsubmit a request for reimbursement from the stop loss fund on forms\nprescribed by the superintendent. The requests for reimbursement shall\nbe submitted no later than April first following the end of the calendar\nyear for which the reimbursement requests are being made. The\nsuperintendent may require health maintenance organizations,\ncorporations or insurers to submit such claims data in connection with\nthe reimbursement requests as he deems necessary to enable him to\ndistribute monies and oversee the operation of the small employer stop\nloss fund. The superintendent may require that such data be submitted on\na per member, aggregate and/or categorical basis.\n (g) For the stop loss fund, the superintendent shall calculate the\ntotal claims reimbursement amount for all health maintenance\norganizations, corporations or insurers for the calendar year for which\nclaims are being reported.\n (1) In the event that the total amount requested for reimbursement for\na calendar year exceeds funds available for distribution for claims paid\nduring that same calendar year, the superintendent shall provide for the\npro-rata distribution of the available funds. Each health maintenance\norganization, corporation or insurer shall be eligible to receive only\nsuch proportionate amount of the available funds as the individual\nhealth maintenance organization's, corporation's or insurer's total\neligible claims paid bears to the total eligible claims paid by all\nhealth maintenance organizations, corporations or insurers.\n (2) In the event that funds available for distribution for claims paid\nby all health maintenance organizations, corporations or insurers during\na calendar year exceeds the total amount requested for reimbursement by\nall health maintenance organizations, corporations or insurers during\nthat same calendar year, any excess funds shall be carried forward and\nmade available for distribution in the next calendar year. Such excess\nfunds shall be in addition to the monies appropriated for the stop loss\nfund in the next calendar year.\n (h) Upon the request of the superintendent, each health maintenance\norganization shall be required to furnish such data as the\nsuperintendent deems necessary to oversee the operation of the small\nemployer stop loss fund. Such data shall be furnished in a form\nprescribed by the superintendent. Each health maintenance organization,\ncorporation or insurer shall provide the superintendent with monthly\nreports of the total enrollment under the qualifying group health\ninsurance contracts issued pursuant to section four thousand three\nhundred twenty-six of this article. The reports shall be in a form\nprescribed by the superintendent.\n (i) The superintendent shall separately estimate the per member annual\ncost of total claims reimbursement from each stop loss fund for\nqualifying group health insurance contracts based upon available data\nand appropriate actuarial assumptions. Upon request, each health\nmaintenance organization, corporation or insurer shall furnish to the\nsuperintendent claims experience data for use in such estimations.\n (j) The superintendent shall determine total eligible enrollment under\nqualifying group health insurance contracts. The total eligible\nenrollment shall be determined by dividing the total funds available for\ndistribution from the small employer stop loss fund by the estimated per\nmember annual cost of total claims reimbursement from the small employer\nstop loss fund.\n (k) The superintendent shall suspend the enrollment of new employers\nunder qualifying group health insurance contracts if the superintendent\ndetermines that the total enrollment reported by all health maintenance\norganizations, corporations or insurers under such contracts exceeds the\ntotal eligible enrollment, thereby resulting in anticipated annual\nexpenditures from the small employer stop loss fund in excess of the\ntotal funds available for distribution from such stop loss fund.\n (l) The superintendent shall provide the health maintenance\norganizations, corporations or insurers with notification of any\nenrollment suspensions as soon as practicable after receipt of all\nenrollment data.\n (m) If at any point during a suspension of enrollment of new\nqualifying small employers, the superintendent determines that funds are\nsufficient to provide for the addition of new enrollments, the\nsuperintendent shall be authorized to reactivate new enrollments and to\nnotify all health maintenance organizations, corporations or insurers\nthat enrollment of new employers may again commence.\n (m-1) In the event that the superintendent suspends the enrollment of\nnew individuals for qualifying group health insurance contracts, the\nsuperintendent shall ensure that small employers seeking to enroll in a\nqualified group health insurance contract pursuant to section\nforty-three hundred twenty-six of this article are provided information\non and directed to coverage options available through the health benefit\nexchange established by this state.\n (n) The suspension of issuance of qualifying group health insurance\ncontracts to new qualifying small employers shall not preclude the\naddition of new employees of an employer already covered under such a\ncontract or new dependents of employees already covered under such\ncontracts.\n (o) The premiums for qualifying group health insurance contracts must\nfactor in the availability of reimbursement from the small employer stop\nloss fund.\n (p) The superintendent may obtain the services of an organization to\nadminister the stop loss funds established by this section. The\nsuperintendent shall establish guidelines for the submission of\nproposals by organizations for the purposes of administering the funds.\nThe superintendent shall make a determination whether to approve,\ndisapprove or recommend modification to the proposal of an applicant to\nadminister the funds. An organization approved to administer the funds\nshall submit reports to the superintendent in such form and at times as\nmay be required by the superintendent in order to facilitate evaluation\nand ensure orderly operation of the funds, including an annual report of\nthe affairs and operations of the fund, such report to be delivered to\nthe superintendent and to the chairs of the senate finance committee and\nthe assembly ways and means committee. An organization approved to\nadminister the funds shall maintain records in a form prescribed by the\nsuperintendent and which shall be available for inspection by or at the\nrequest of the superintendent. The superintendent shall determine the\namount of compensation to be allocated to an approved organization as\npayment for fund administration. Compensation shall be payable from the\nstop loss coverage funds. An organization approved to administer the\nfunds may be removed by the superintendent and must cooperate in the\norderly transition of services to another approved organization or to\nthe superintendent.\n (q) If the superintendent deems it appropriate for the proper\nadministration of the small employer stop loss fund, the administrator\nof the fund, on behalf of and with the prior approval of the\nsuperintendent, shall be authorized to purchase stop loss insurance\nand/or reinsurance from an insurance company licensed to write such type\nof insurance in this state. Such stop loss insurance and/or reinsurance\nmay be purchased to the extent of funds available therefor within such\nfunds which are available for purposes of the stop loss funds\nestablished by this section.\n (r) The superintendent may access funding from the small employer stop\nloss fund for the purposes of developing and implementing public\neducation, outreach and facilitated enrollment strategies targeted to\nsmall employers without health insurance. The superintendent may\ncontract with marketing organizations to perform or provide assistance\nwith such education, outreach, and enrollment strategies. The\nsuperintendent shall determine the amount of funding available for the\npurposes of this subsection which in no event shall exceed eight percent\nof the annual funding amounts for the small employer stop loss fund.\n (s) Brooklyn healthworks pilot program and upstate healthworks pilot\nprogram. Commencing on July first, two thousand six, the superintendent\nshall access funding from the small employer stop loss fund for the\npurpose of support and expansion of the existing pilot program Brooklyn\nhealthworks approved by the superintendent and for the establishment and\noperation of a pilot program to be located in upstate New York. For the\npurpose of this subsection, in no event shall the amount of funding\navailable exceed two percent of the annual funding amount for the small\nemployer stop loss fund.\n
