Stop Loss Program

Stop Loss is a type of reinsurance, or risk protection, offered by NYS to Medicaid managed care plans, which is intended to limit the plan's liability for individual enrollees. The State agrees to pay for costs incurred by the plan that exceed a certain threshold amount. Stop Loss payments are in addition to the monthly capitation payment made by New York State (NYS) for each enrollee.

Plans providing comprehensive benefits under the State's 1115 waiver to all eligible Medicaid enrollees may elect to purchase reinsurance from NYS to cover the following expenditures:

  • General Inpatient
  • Inpatient HIV/SNP (Special Needs Plan)
  • Mental Health and Alcohol and Substance Abuse
  • Modification/Update to Residential Health Care Facility (Nursing Home) through 12/31/2021

Encounter Issues:

If your plan is experiencing encounter issues, the Stop Loss Unit cannot assist you with this. You will need to contact the Medicaid Data Unit. The mailbox address is: omcmeds@health.ny.gov

If a plan receives a Failure message "Encounter Not on File" for a particular stay(s), and would like to initiate a first-level inquiry through Stop Loss, and the plan has proof that one exists and was "accepted," the following documentation is required:

  • Claim Failure to Process Summary File Submission Date/Report Date
  • CIN, Admit Date, Discharge Date*
  • APD ICN and File name*

*This information should be in an Excel file.

What's New

  • General Inpatient
    • Effective 1/1/2025, the calendar year general inpatient Stop Loss threshold will be increased from $200,000 to $400,000 for 80% reimbursement and from $350,000 to $700,000 for 100% reimbursement.
  • HIV - Special Needs Plans (SNPs)
    • Effective 1/1/2025, the calendar year HIV-SNP Stop Loss threshold will be increased from $200,000 to $400,000 for 85% reimbursement and from $400,000 to $800,000 for 100% reimbursement.
  • Two-Year Review Waiver Requests
    • Effective June 1, 2025, two-year waiver requests will be accepted electronically by FAX or e-mail as well as by postal mail. Two-year waiver requests for claims payment are considered when the submission of claims is greater than two years from the date of service. Requests and supporting documentation must be received within 60 days of the date on the remittance advice.
    • Written requests may be submitted in the following ways:
      1. FAX 518-473-6708
      2. Secure emails: pend@health.ny.gov
      3. Paper submission mailed to the address below:
        • New York State Department of Health
          Two Year Claim Review
          1 Commerce Plaza, Room 1206
          Albany, NY 12210

Supporting documentation (cover letter with explanation of delay and sequence of events, remittance statements, notice of eligibility, fair hearing decision, court order decision, evidence of agency error, etc.) and a copy of the current remittance advice documenting the edit 01292 denial must accompany all requests.

Claims submitted for review without the appropriate documentation, or those not submitted within the 60-day period from the remittance advice will not be considered.

Questions should be directed to 1-800-342-3005, option 3 or sent to pend@health.ny.gov.