S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   10601
 
                           I N  A S S E M B L Y
 
                               June 20, 2024
                                ___________
 
 Introduced by COMMITTEE ON RULES -- (at request of M. of A. Lee) -- read
   once and referred to the Committee on Insurance
 
 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
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Paragraph 1 of subsection (c) of section 4235 of the insur-
 ance law is amended by adding a new subparagraph (O) as follows:
   (O) A POLICY ISSUED TO  AN  ACCOUNTABLE  CARE  ORGANIZATION  ISSUED  A
 CERTIFICATE  OF  AUTHORIZATION  PURSUANT TO ARTICLE TWENTY-NINE-E OF THE
 PUBLIC HEALTH LAW, OR TO A TRUSTEE OR TRUSTEES OF  A  FUND  ESTABLISHED,
 CREATED OR MAINTAINED FOR THE BENEFIT OF MEMBERS OF ONE OR MORE ACCOUNT-
 ABLE  CARE  ORGANIZATIONS ISSUED A CERTIFICATE OF AUTHORIZATION PURSUANT
 TO ARTICLE TWENTY-NINE-E OF THE PUBLIC HEALTH LAW, ALL OF WHOSE ELIGIBLE
 MEMBERS HAVE THE  SAME  PROFESSION,  TRADE  OR  OCCUPATION  PROVIDED  OR
 RELATED  TO  THE  PROVISION OF HEALTH CARE, WHICH ASSOCIATION OR ASSOCI-
 ATIONS HAVE BEEN ORGANIZED AND MAINTAINED IN  GOOD  FAITH  FOR  PURPOSES
 PRINCIPALLY  OTHER  THAN  THAT  OF  OBTAINING INSURANCE AND HAVE BEEN IN
 ACTIVE EXISTENCE FOR  AT  LEAST  TWO  YEARS.  THE  POLICY  SHALL  INSURE
 MEMBERS,  OR EMPLOYEES OF MEMBERS, OF SUCH ACCOUNTABLE CARE ORGANIZATION
 OR ORGANIZATIONS FOR THE BENEFIT OF PERSONS OTHER THAN EMPLOYERS AND THE
 ACCOUNTABLE CARE ORGANIZATION OR ORGANIZATIONS, OR ANY OFFICIALS, REPRE-
 SENTATIVES, TRUSTEES OR AGENTS THEREOF AND SHALL PROVIDE FOR  THE  ISSU-
 ANCE  OF  A  CERTIFICATE  TO  THE PERSONS INSURED OR SUCH BENEFICIARY AS
 EVIDENCE OF SUCH INSURANCE. THE MEMBERS OR EMPLOYEES  ELIGIBLE  FOR  THE
 INSURANCE  UNDER THE POLICY SHALL BE ALL THE MEMBERS, OR ALL THE MEMBERS
 AND THEIR EMPLOYEES, OR ALL OF ANY CLASS OR CLASSES  THEREOF  DETERMINED
 BY  CONDITIONS PERTAINING TO THEIR EMPLOYMENT OR TO THE ACCOUNTABLE CARE
 ORGANIZATION MEMBERSHIP OR BOTH. THE PREMIUMS FOR THE  POLICY  SHALL  BE
 PAID FROM THE ACCOUNTABLE CARE ORGANIZATION OR MEMBERS' FUNDS, OR PARTLY
 FROM  SUCH  FUNDS AND PARTLY FROM FUNDS CONTRIBUTED BY THE INSURED INDI-
 VIDUALS, OR FROM FUNDS WHOLLY CONTRIBUTED BY THE INSURED INDIVIDUALS.  A
 POLICY ON WHICH ALL OR PART OF THE PREMIUM IS TO BE DERIVED  FROM  FUNDS
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD15655-01-4
 A. 10601                            2
 
 CONTRIBUTED  BY THE INSURED INDIVIDUALS SPECIFICALLY FOR THEIR INSURANCE
 MUST INSURE AT LEAST FIFTY PERCENT OF THE THEN ELIGIBLE INDIVIDUALS OR A
 MINIMUM OF FIVE HUNDRED INDIVIDUALS, WHICHEVER IS LESS, EXCLUDING ANY AS
 TO  WHOM  EVIDENCE OF INDIVIDUAL INSURABILITY IS NOT SATISFACTORY TO THE
 INSURER. A POLICY ON WHICH NO PART OF THE PREMIUM IS TO BE DERIVED  FROM
 FUNDS  CONTRIBUTED  BY  THE  INSURED  INDIVIDUALS SPECIFICALLY FOR THEIR
 INSURANCE MUST COVER ALL ELIGIBLE INDIVIDUALS, EXCLUDING ANY AS TO  WHOM
 EVIDENCE  OF INDIVIDUAL INSURABILITY IS NOT SATISFACTORY TO THE INSURER.
 IN EVERY CASE THE POLICY MUST COVER AT LEAST ONE HUNDRED INDIVIDUALS  AT
 DATE  OF  ISSUE.  THE  INSURANCE COVERAGE ON EMPLOYEES INSURED UNDER THE
 POLICY SHALL BE BASED UPON SOME PLAN  PRECLUDING  INDIVIDUAL  SELECTION.
 HOWEVER,  WITH RESPECT TO SUCH FUND, OR ACCOUNTABLE CARE ORGANIZATION OR
 ACCOUNTABLE CARE ORGANIZATIONS, SUCH A  PLAN  MAY  PERMIT  A  NUMBER  OF
 SELECTIONS  BY  THE  FUND,  ACCOUNTABLE CARE ORGANIZATION OR ACCOUNTABLE
 CARE ORGANIZATIONS IF THE SELECTIONS OFFERED UTILIZE CONSISTENT PLANS OF
 COVERAGE SO  THAT  THE  RESULTING  PLANS  OF  COVERAGE  ARE  REASONABLE.
 FURTHERMORE,  SUCH  A  PLAN  MAY  PERMIT  A LIMITED NUMBER OF SELECTIONS
 OFFERED BY EMPLOYEES  OR  MEMBERS  IF  THE  SELECTIONS  OFFERED  UTILIZE
 CONSISTENT  PLANS  OF  COVERAGE FOR INDIVIDUAL GROUP MEMBERS SO THAT THE
 RESULTING PLANS OF COVERAGE ARE REASONABLE.  IF  A  POLICY  DIVIDEND  IS
 DECLARED OR A REDUCTION IN RATE IS MADE UNDER SUCH A POLICY, THE EXCESS,
 IF  ANY,  OF THE AGGREGATE DIVIDENDS OR RATE REDUCTIONS UNDER THE POLICY
 OVER THE AGGREGATE EXPENDITURE FOR INSURANCE UNDER SUCH POLICY MADE FROM
 THE ACCOUNTABLE CARE ORGANIZATION OR EMPLOYER FUNDS, INCLUDING  EXPENDI-
 TURES  MADE  IN  CONNECTION WITH ADMINISTRATION OF SUCH POLICY, SHALL BE
 APPLIED BY THE POLICYHOLDER FOR THE SOLE BENEFIT OF THE INSURED INDIVID-
 UALS. A POLICY ISSUED PURSUANT TO  THIS  SUBPARAGRAPH  SHALL  PROVIDE  A
 CONVERSION  PRIVILEGE  NO  LESS  FAVORABLE  THAN  THAT  PROVIDED  FOR IN
 SUBSECTION (E) OF SECTION THREE THOUSAND TWO HUNDRED TWENTY-ONE OF  THIS
 CHAPTER.
   §  2.  Subsection (g) of section 3231 of the insurance law, as amended
 by section 70 of part D of chapter 56 of the laws of 2013,  paragraph  1
 as  amended  by  chapter  12  of the laws of 2016, is amended to read as
 follows:
   (g)  (1)  UNLESS  OTHERWISE  DESCRIBED  IN  PARAGRAPH  THREE  OF  THIS
 SUBSECTION:  (A)  This  section shall also apply to policies issued to a
 group defined in subsection (c) of section  four  thousand  two  hundred
 thirty-five of this chapter, including but not limited to an association
 or  trust of employers, if the group includes one or more member employ-
 ers or other member groups having one  hundred  or  fewer  employees  or
 members  exclusive  of  spouses  and  dependents. For a policy issued or
 renewed on or after January first, two thousand fourteen, if  the  group
 includes  one or more member small group employers eligible for coverage
 subject to this section, then such member employers shall be  classified
 as  small  groups for rating purposes and the remaining members shall be
 rated consistent with the rating  rules  applicable  to  such  remaining
 members pursuant to paragraph two of this subsection. (B) Subparagraph A
 of  this  paragraph  shall  not  apply to either the renewal of a policy
 issued to a group or the issuance, between January first,  two  thousand
 sixteen  and  December  thirty-first, two thousand sixteen, of a policy,
 and any renewal thereof, to a group, provided that the  following  three
 requirements are met: (I) the group had been issued a policy that was in
 effect  on  July  first, two thousand fifteen; (II) the group had member
 employers, who, on or after  July  first,  two  thousand  fifteen,  have
 between  fifty-one  and  one hundred employees, exclusive of spouses and
 dependents; and (III) the group is either: (i) comprised entirely of one
 A. 10601                            3
 
 or more municipal corporations or districts (as such terms  are  defined
 in section one hundred nineteen-n of the general municipal law); or (ii)
 comprised entirely of nonpublic schools providing education in any grade
 from pre-kindergarten through twelfth grade.
   (2)  [If]  UNLESS  OTHERWISE  DESCRIBED  IN  PARAGRAPH  THREE  OF THIS
 SUBSECTION, IF a policy is issued to a group defined in  subsection  (c)
 of  section  four  thousand  two  hundred  thirty-five  of this chapter,
 including an association group, that includes one or more individual  or
 individual  proprietor  members,  for  rating purposes the insurer shall
 include such members in its individual pool  of  risks  in  establishing
 premium rates for such members.
   (3)  THIS  SUBSECTION  SHALL  NOT  APPLY TO A POLICY ISSUED TO A GROUP
 DEFINED IN SUBPARAGRAPH (O)  OF  PARAGRAPH  ONE  OF  SUBSECTION  (C)  OF
 SECTION  FOUR  THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER, EVEN IF
 THE GROUP INCLUDES ONE OR MORE MEMBER EMPLOYERS OR OTHER  MEMBER  GROUPS
 WHICH HAVE ONE HUNDRED OR FEWER EMPLOYEES OR MEMBERS EXCLUSIVE OF SPOUS-
 ES AND DEPENDENTS, IF THE FOLLOWING CRITERIA ARE MET:
   (A)  THE  GROUP  IS  COMPRISED  OF  AT  LEAST ONE HUNDRED FIFTY MEMBER
 EMPLOYERS;
   (B) THE COLLECTIVE NUMBER OF  INDIVIDUALS  INSURED  UNDER  THE  POLICY
 EXCEEDS FIVE HUNDRED PERSONS;
   (C)  EACH  EMPLOYER  IN  THE  GROUP  IS  ENROLLED AS A PROVIDER IN THE
 STATE'S MEDICAID PROGRAM; AND
   (D) EACH EMPLOYER IN THE GROUP CAN DEMONSTRATE AN ANNUAL PAYER MIX  IN
 WHICH MEDICAID REPRESENTS SIXTY PERCENT OR MORE OF ANNUAL REVENUES.
   §  3.  Paragraph  1 of subsection (d) of section 4317 of the insurance
 law, as amended by chapter 12 of the laws of 2016, is amended and a  new
 paragraph 4 is added to read as follows:
   (1)  (A)  [This]  UNLESS OTHERWISE DESCRIBED IN PARAGRAPH FOUR OF THIS
 SUBSECTION, THIS section shall also apply to  a  contract  issued  to  a
 group  defined  in  subsection  (c) of section four thousand two hundred
 thirty-five of this chapter, including but not limited to an association
 or trust of employers, if the group includes one or more member  employ-
 ers  or  other  member  groups  having one hundred or fewer employees or
 members exclusive of spouses and dependents. For a  contract  issued  or
 renewed  on  or after January first, two thousand fourteen, if the group
 includes one or more member small group employers eligible for  coverage
 subject  to this section, then such member employers shall be classified
 as small groups for rating purposes and the remaining members  shall  be
 rated  consistent  with  the  rating  rules applicable to such remaining
 members pursuant to paragraph two of this subsection. (B) Subparagraph A
 of this paragraph shall not apply to either the renewal  of  a  contract
 issued  to  a group or the issuance, between January first, two thousand
 sixteen and December thirty-first, two thousand sixteen, of a  contract,
 and  any  renewal thereof, to a group, provided that the following three
 requirements are met: (I) the group had been issued a contract that  was
 in effect on July first, two thousand fifteen; (II) the group had member
 employers,  who,  on  or  after  July  first, two thousand fifteen, have
 between fifty-one and one hundred employees, exclusive  of  spouses  and
 dependents; and (III) the group is either: (i) comprised entirely of one
 or  more  municipal corporations or districts (as such terms are defined
 in section one hundred nineteen-n of the general municipal law); or (ii)
 comprised entirely of nonpublic schools providing education in any grade
 from pre-kindergarten through twelfth grade.
   (4) THIS SUBSECTION SHALL NOT APPLY TO A  POLICY  ISSUED  TO  A  GROUP
 DEFINED  IN PARAGRAPH (O) OF SUBSECTION (C) OF SECTION FOUR THOUSAND TWO
 A. 10601                            4
 
 HUNDRED THIRTY-FIVE OF THIS CHAPTER, EVEN IF THE GROUP INCLUDES  ONE  OR
 MORE  MEMBER  EMPLOYERS OR OTHER MEMBER GROUPS WHICH HAVE ONE HUNDRED OR
 FEWER EMPLOYEES OR MEMBERS EXCLUSIVE OF SPOUSES AND DEPENDENTS,  IF  THE
 FOLLOWING CRITERIA ARE MET:
   (A)  THE  GROUP  IS  COMPRISED  OF  AT  LEAST ONE HUNDRED FIFTY MEMBER
 EMPLOYERS;
   (B) THE COLLECTIVE NUMBER OF  INDIVIDUALS  INSURED  UNDER  THE  POLICY
 EXCEEDS FIVE HUNDRED PERSONS;
   (C)  EACH  EMPLOYER  IN  THE  GROUP  IS  ENROLLED AS A PROVIDER IN THE
 STATE'S MEDICAID PROGRAM; AND
   (D) EACH EMPLOYER IN THE GROUP CAN DEMONSTRATE AN ANNUAL PAYER MIX  IN
 WHICH MEDICAID REPRESENTS SIXTY PERCENT OR MORE OF ANNUAL REVENUES.
   § 4. This act shall take effect on the one hundred eightieth day after
 it  shall  have  become a law; provided, however, that the amendments to
 paragraph (1) of subsection (g) of section 3231  and  paragraph  (1)  of
 subsection (d) of section 4317 of the insurance law made by sections two
 and three of this act shall not affect the expiration of such paragraphs
 and shall be deemed to expire therewith.