S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  6522--A
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                               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
 
   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  A  MEDICAID  ACCOUNTABLE CARE ORGANIZATION
 COMPRISED WHOLLY OF PRIVATE PHYSICIAN PRACTICES 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 MAIN-
 TAINED FOR THE BENEFIT OF MEMBERS OF ONE OR  MORE  MEDICAID  ACCOUNTABLE
 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  MEDICAID  ACCOUNTABLE  CARE
 ORGANIZATION  OR  ORGANIZATIONS  FOR  THE  BENEFIT OF PERSONS OTHER THAN
 EMPLOYERS AND THE MEDICAID ACCOUNTABLE CARE  ORGANIZATION  OR  ORGANIZA-
 TIONS, OR ANY OFFICIALS, REPRESENTATIVES, TRUSTEES OR AGENTS THEREOF AND
 SHALL  PROVIDE  FOR THE ISSUANCE 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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03606-02-5
              

 A. 6522--A                          2
 
 OR TO THE MEDICAID ACCOUNTABLE CARE ORGANIZATION MEMBERSHIP OR BOTH. THE
 PREMIUMS FOR THE POLICY SHALL BE PAID FROM THE MEDICAID ACCOUNTABLE CARE
 ORGANIZATION OR MEMBERS' FUNDS, OR PARTLY FROM  SUCH  FUNDS  AND  PARTLY
 FROM  FUNDS CONTRIBUTED BY THE INSURED INDIVIDUALS, 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 CONTRIBUTED BY THE INSURED
 INDIVIDUALS SPECIFICALLY FOR THEIR INSURANCE SHALL 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  MEDICAID  ACCOUNTABLE CARE ORGANIZATION OR MEDICAID
 ACCOUNTABLE CARE ORGANIZATIONS, SUCH A  PLAN  MAY  PERMIT  A  NUMBER  OF
 SELECTIONS  BY THE FUND, MEDICAID ACCOUNTABLE CARE ORGANIZATION OR MEDI-
 CAID 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  DIVI-
 DEND 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 MEDICAID ACCOUNTABLE CARE ORGANIZATION OR EMPLOYER FUNDS,
 INCLUDING EXPENDITURES MADE IN CONNECTION WITH  ADMINISTRATION  OF  SUCH
 POLICY, SHALL BE APPLIED BY THE POLICYHOLDER FOR THE SOLE BENEFIT OF THE
 INSURED INDIVIDUALS. 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,
 A. 6522--A                          3
 
 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
 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
 A. 6522--A                          4

 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
 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.