N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 362-5.5

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

Section 362-5.5 - Data filing requirements

(a) The superintendent shall require the submission of necessary claims data in connection with each health maintenance organization's and participating insurer's annual submission of requests for reimbursement from the stop loss funds. Each health maintenance organization and participating insurer shall also provide the superintendent with such additional data, as he deems necessary, to oversee the operation of the stop loss funds and the Healthy New York Program. Reports pertaining to stop loss reimbursement or loss ratio shall be certified by an officer of the company that such report is accurate and complete. Data to be submitted may include, but shall not be limited to, the following:

(1) the total number of contracts issued within the reporting period and the total number of contracts in force which are covered by the stop loss fund;

(2) the number of qualifying individual health insurance contracts issued which do not provide coverage for dependents;

(3) the number of qualifying small employer health insurance contracts where the employer elects not to make dependent coverage available to employees;

(4) the total number of primary insureds, the total number of dependents covered, and the total number of child dependents covered (a breakdown of these totals by geographic region may be required);

(5) total premium earned and per member per month premium earned for all contracts covered by the stop loss fund for the reporting period;

(6) claims payment data, reported individually for each covered member and/or for each covered member for whom the health maintenance organization or participating insurer has paid claims eligible for reimbursement;

(7) total claims eligible for reimbursement year to date; and

(8) paid claims continuance tables containing the number of claimants and the total number of claims paid by claimant dollar intervals. The superintendent shall provide a written and electronic spreadsheet with specific claimant dollar intervals and any partitions of paid claims other than by stop loss fund.

(b) Data must be reported separately for each stop loss fund. Data reporting periods may be other than a calendar year and reporting frequency for some data could be as often as monthly. Claims payment data shall clearly set forth both the date the claim was incurred and the date the claim was paid. Claims payment data may also be requested on a cumulative basis or in the form of aggregates, categoricals, and averages.

(c) A health maintenance organization or participating insurer shall use a coding system to ensure the privacy of insured individuals. Personally identifying information shall not be submitted with claims data.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 362-5.5