N.Y. Comp. Codes R. & Regs. tit. 11 § 361.4

Current through Register Vol. 46, No. 43, October 23, 2024

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

(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.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 361.4