| 1 | 1 | | <STYLE><!--U {color: Green}S {color: RED} I {color: DARKBLUE; background-color:yellow} P.brk {page-break-before:always}--></STYLE> <BASEFONT SIZE=3> <PRE WIDTH="108"> <FONT SIZE=5><B> STATE OF NEW YORK</B></FONT> ________________________________________________________________________ 6522--A 2025-2026 Regular Sessions <FONT SIZE=5><B> IN ASSEMBLY</B></FONT> March 5, 2025 ___________ Introduced by M. of A. LEE -- read once and referred to the Committee on Insurance -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee AN ACT to amend the insurance law, in relation to allowing for Medicaid accountable care organizations to purchase experience-rated health insurance for their members <B><U>The People of the State of New York, represented in Senate and Assem-</U></B> <B><U>bly, do enact as follows:</U></B> 1 Section 1. Paragraph 1 of subsection (c) of section 4235 of the insur- 2 ance law is amended by adding a new subparagraph (O) as follows: 3 <B><U>(O) A policy issued to a Medicaid accountable care organization</U></B> 4 <B><U>comprised wholly of private physician practices issued a certificate of</U></B> 5 <B><U>authorization pursuant to article twenty-nine-E of the public health</U></B> 6 <B><U>law, or to a trustee or trustees of a fund established, created or main-</U></B> 7 <B><U>tained for the benefit of members of one or more Medicaid accountable</U></B> 8 <B><U>care organizations issued a certificate of authorization pursuant to</U></B> 9 <B><U>article twenty-nine-E of the public health law, all of whose eligible</U></B> 10 <B><U>members have the same profession, trade or occupation provided or</U></B> 11 <B><U>related to the provision of health care, which association or associ-</U></B> 12 <B><U>ations have been organized and maintained in good faith for purposes</U></B> 13 <B><U>principally other than that of obtaining insurance and have been in</U></B> 14 <B><U>active existence for at least two years. The policy shall insure</U></B> 15 <B><U>members, or employees of members, of such Medicaid accountable care</U></B> 16 <B><U>organization or organizations for the benefit of persons other than</U></B> 17 <B><U>employers and the Medicaid accountable care organization or organiza-</U></B> 18 <B><U>tions, or any officials, representatives, trustees or agents thereof and</U></B> 19 <B><U>shall provide for the issuance of a certificate to the persons insured</U></B> 20 <B><U>or such beneficiary as evidence of such insurance. The members or</U></B> 21 <B><U>employees eligible for the insurance under the policy shall be all the</U></B> 22 <B><U>members, or all the members and their employees, or all of any class or</U></B> 23 <B><U>classes thereof determined by conditions pertaining to their employment</U></B> EXPLANATION--Matter in <B><U>italics</U></B> (underscored) is new; matter in brackets [<B><S> </S></B>] is old law to be omitted. LBD03606-02-5 </PRE><P CLASS="brk"><PRE WIDTH="108"> A. 6522--A 2 1 <B><U>or to the Medicaid accountable care organization membership or both. The</U></B> 2 <B><U>premiums for the policy shall be paid from the Medicaid accountable care</U></B> 3 <B><U>organization or members' funds, or partly from such funds and partly</U></B> 4 <B><U>from funds contributed by the insured individuals, or from funds wholly</U></B> 5 <B><U>contributed by the insured individuals. A policy on which all or part</U></B> 6 <B><U>of the premium is to be derived from funds contributed by the insured</U></B> 7 <B><U>individuals specifically for their insurance shall insure at least fifty</U></B> 8 <B><U>percent of the then eligible individuals or a minimum of five hundred</U></B> 9 <B><U>individuals, whichever is less, excluding any as to whom evidence of</U></B> 10 <B><U>individual insurability is not satisfactory to the insurer. A policy on</U></B> 11 <B><U>which no part of the premium is to be derived from funds contributed by</U></B> 12 <B><U>the insured individuals specifically for their insurance must cover all</U></B> 13 <B><U>eligible individuals, excluding any as to whom evidence of individual</U></B> 14 <B><U>insurability is not satisfactory to the insurer. In every case the</U></B> 15 <B><U>policy must cover at least one hundred individuals at date of issue. The</U></B> 16 <B><U>insurance coverage on employees insured under the policy shall be based</U></B> 17 <B><U>upon some plan precluding individual selection. However, with respect</U></B> 18 <B><U>to such fund, or Medicaid accountable care organization or Medicaid</U></B> 19 <B><U>accountable care organizations, such a plan may permit a number of</U></B> 20 <B><U>selections by the fund, Medicaid accountable care organization or Medi-</U></B> 21 <B><U>caid accountable care organizations if the selections offered utilize</U></B> 22 <B><U>consistent plans of coverage so that the resulting plans of coverage are</U></B> 23 <B><U>reasonable. Furthermore, such a plan may permit a limited number of</U></B> 24 <B><U>selections offered by employees or members if the selections offered</U></B> 25 <B><U>utilize consistent plans of coverage for individual group members so</U></B> 26 <B><U>that the resulting plans of coverage are reasonable. If a policy divi-</U></B> 27 <B><U>dend is declared or a reduction in rate is made under such a policy, the</U></B> 28 <B><U>excess, if any, of the aggregate dividends or rate reductions under the</U></B> 29 <B><U>policy over the aggregate expenditure for insurance under such policy</U></B> 30 <B><U>made from the Medicaid accountable care organization or employer funds,</U></B> 31 <B><U>including expenditures made in connection with administration of such</U></B> 32 <B><U>policy, shall be applied by the policyholder for the sole benefit of the</U></B> 33 <B><U>insured individuals. A policy issued pursuant to this subparagraph shall</U></B> 34 <B><U>provide a conversion privilege no less favorable than that provided for</U></B> 35 <B><U>in subsection (e) of section three thousand two hundred twenty-one of</U></B> 36 <B><U>this chapter.</U></B> 37 § 2. Subsection (g) of section 3231 of the insurance law, as amended 38 by section 70 of part D of chapter 56 of the laws of 2013, paragraph 1 39 as amended by chapter 12 of the laws of 2016, is amended to read as 40 follows: 41 (g) (1) <B><U>Unless otherwise described in paragraph three of this</U></B> 42 <B><U>subsection:</U></B> (A) This section shall also apply to policies issued to a 43 group defined in subsection (c) of section four thousand two hundred 44 thirty-five of this chapter, including but not limited to an association 45 or trust of employers, if the group includes one or more member employ- 46 ers or other member groups having one hundred or fewer employees or 47 members exclusive of spouses and dependents. For a policy issued or 48 renewed on or after January first, two thousand fourteen, if the group 49 includes one or more member small group employers eligible for coverage 50 subject to this section, then such member employers shall be classified 51 as small groups for rating purposes and the remaining members shall be 52 rated consistent with the rating rules applicable to such remaining 53 members pursuant to paragraph two of this subsection. (B) Subparagraph A 54 of this paragraph shall not apply to either the renewal of a policy 55 issued to a group or the issuance, between January first, two thousand 56 sixteen and December thirty-first, two thousand sixteen, of a policy, </PRE><P CLASS="brk"><PRE WIDTH="108"> A. 6522--A 3 1 and any renewal thereof, to a group, provided that the following three 2 requirements are met: (I) the group had been issued a policy that was in 3 effect on July first, two thousand fifteen; (II) the group had member 4 employers, who, on or after July first, two thousand fifteen, have 5 between fifty-one and one hundred employees, exclusive of spouses and 6 dependents; and (III) the group is either: (i) comprised entirely of one 7 or more municipal corporations or districts (as such terms are defined 8 in section one hundred nineteen-n of the general municipal law); or (ii) 9 comprised entirely of nonpublic schools providing education in any grade 10 from pre-kindergarten through twelfth grade. 11 (2) [<B><S>If</S></B>] <B><U>Unless otherwise described in paragraph three of this</U></B> 12 <B><U>subsection, if</U></B> a policy is issued to a group defined in subsection (c) 13 of section four thousand two hundred thirty-five of this chapter, 14 including an association group, that includes one or more individual or 15 individual proprietor members, for rating purposes the insurer shall 16 include such members in its individual pool of risks in establishing 17 premium rates for such members. 18 <B><U>(3) This subsection shall not apply to a policy issued to a group</U></B> 19 <B><U>defined in subparagraph (O) of paragraph one of subsection (c) of</U></B> 20 <B><U>section four thousand two hundred thirty-five of this chapter, even if</U></B> 21 <B><U>the group includes one or more member employers or other member groups</U></B> 22 <B><U>which have one hundred or fewer employees or members exclusive of spous-</U></B> 23 <B><U>es and dependents, if the following criteria are met:</U></B> 24 <B><U>(A) the group is comprised of at least one hundred fifty member</U></B> 25 <B><U>employers;</U></B> 26 <B><U>(B) the collective number of individuals insured under the policy</U></B> 27 <B><U>exceeds five hundred persons;</U></B> 28 <B><U>(C) each employer in the group is enrolled as a provider in the</U></B> 29 <B><U>state's Medicaid program; and</U></B> 30 <B><U>(D) each employer in the group can demonstrate an annual payer mix in</U></B> 31 <B><U>which Medicaid represents sixty percent or more of annual revenues.</U></B> 32 § 3. Paragraph 1 of subsection (d) of section 4317 of the insurance 33 law, as amended by chapter 12 of the laws of 2016, is amended and a new 34 paragraph 4 is added to read as follows: 35 (1) (A) [<B><S>This</S></B>] <B><U>Unless otherwise described in paragraph four of this</U></B> 36 <B><U>subsection, this</U></B> section shall also apply to a contract issued to a 37 group defined in subsection (c) of section four thousand two hundred 38 thirty-five of this chapter, including but not limited to an association 39 or trust of employers, if the group includes one or more member employ- 40 ers or other member groups having one hundred or fewer employees or 41 members exclusive of spouses and dependents. For a contract issued or 42 renewed on or after January first, two thousand fourteen, if the group 43 includes one or more member small group employers eligible for coverage 44 subject to this section, then such member employers shall be classified 45 as small groups for rating purposes and the remaining members shall be 46 rated consistent with the rating rules applicable to such remaining 47 members pursuant to paragraph two of this subsection. (B) Subparagraph A 48 of this paragraph shall not apply to either the renewal of a contract 49 issued to a group or the issuance, between January first, two thousand 50 sixteen and December thirty-first, two thousand sixteen, of a contract, 51 and any renewal thereof, to a group, provided that the following three 52 requirements are met: (I) the group had been issued a contract that was 53 in effect on July first, two thousand fifteen; (II) the group had member 54 employers, who, on or after July first, two thousand fifteen, have 55 between fifty-one and one hundred employees, exclusive of spouses and 56 dependents; and (III) the group is either: (i) comprised entirely of one </PRE><P CLASS="brk"><PRE WIDTH="108"> A. 6522--A 4 1 or more municipal corporations or districts (as such terms are defined 2 in section one hundred nineteen-n of the general municipal law); or (ii) 3 comprised entirely of nonpublic schools providing education in any grade 4 from pre-kindergarten through twelfth grade. 5 <B><U>(4) This subsection shall not apply to a policy issued to a group</U></B> 6 <B><U>defined in paragraph (O) of subsection (c) of section four thousand two</U></B> 7 <B><U>hundred thirty-five of this chapter, even if the group includes one or</U></B> 8 <B><U>more member employers or other member groups which have one hundred or</U></B> 9 <B><U>fewer employees or members exclusive of spouses and dependents, if the</U></B> 10 <B><U>following criteria are met:</U></B> 11 <B><U>(A) the group is comprised of at least one hundred fifty member</U></B> 12 <B><U>employers;</U></B> 13 <B><U>(B) the collective number of individuals insured under the policy</U></B> 14 <B><U>exceeds five hundred persons;</U></B> 15 <B><U>(C) each employer in the group is enrolled as a provider in the</U></B> 16 <B><U>state's Medicaid program; and</U></B> 17 <B><U>(D) each employer in the group can demonstrate an annual payer mix in</U></B> 18 <B><U>which Medicaid represents sixty percent or more of annual revenues.</U></B> 19 § 4. This act shall take effect on the one hundred eightieth day after 20 it shall have become a law; provided, however, that the amendments to 21 paragraph 1 of subsection (g) of section 3231 and paragraph 1 of 22 subsection (d) of section 4317 of the insurance law made by sections two 23 and three of this act shall not affect the expiration of such paragraphs 24 and shall be deemed to expire therewith. |
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