Stop Loss Program

Please note that our website has been updated

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
  • Residential Health Care Facility (Nursing Home)

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

What's New

New York State is moving Medicaid behavioral health services into Managed Care. Behavioral Health Managed Care will integrate all behavioral health (BH) and physical heath (PH) services under the management of Mainstream Medicaid Managed Care Organizations (MCOs) and Health and Recovery Plans (HARP). For the most up-to-date information on HARP, please visit the Office of Mental Health, Behavioral Health Managed Care website.

The parameters for HARP Stop Loss claims are outlined on the phase-in page of this website.