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:

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

  • The Two-Year Review Unit Has Moved
    • The New York State Department of Health Medical Pended Claims Unit, including the Two-Year Review unit, has relocated to the address below. Please send all correspondence to the new address effective immediately.
      New York State Department of Health
      Attn: Medical Pended Claims/Two-Year Claim Review
      1 Commerce Plaza, Room 1206
      Albany, NY 12260

      The phone number remains the same:
      800-342-3005 Option #3
  • General Inpatient
    • Effective 1/1/2022, the calendar year general inpatient Stop Loss threshold will be increased from $100,000 to $200,000 for 80% reimbursement and from $250,000 to $350,000 for 100% reimbursement.
  • HIV - Special Needs Plans (SNPs)
    • Effective 1/1/2022, the calendar year HIV-SNP Stop Loss threshold will be increased from $100,000 to $200,000 for 85% reimbursement and from $300,000 to $400,000 for 100% reimbursement.
  • Residential Health Care Facility
    • Effective 1/1/2022, Stop Loss coverage will no longer be provided for Residential Health Care Facility stays in excess of 60 days per member per calendar year for members who are not in permanent nursing home placement status.