Covered Lives Enrollment Option

November 2, 2011

Re: New York State Health Care Reform Acts of 1996 and 2000 (HCRA)

Dear Payor:

Section 2807-t (4)(f) of the Public Health Law allows electing payors who are designated as monthly filers for their Public Goods Pool (PGP) reports to have the option to establish their covered lives enrollment obligations for the upcoming calendar year on membership units enrolled as of the last day of the month, or to continue to establish their covered lives enrollment obligations on membership units during all or any portion of the month.

If you choose to establish your covered lives obligations as of the last day of the month for calendar year 2012, you must notify the Department between November 1, 2011, and December 31. 2011. You may electronically select this option through the Office of Pool Administration´s Web site during that time at: www.hcrapools.org, select "Payor Monthly Options" then "Covered Lives Enrollment Option." You must have been issued a User ID and password to access this application. If you do not have a User ID and password, we encourage you to complete the DOH-4264, Electronic Filing User ID Application. This form is available on the Department´s Web site at: www.health.ny.gov/nysdoh/hcra/forms.htm.

If you choose to file a hardcopy form to establish your covered lives obligations as of the last day of the month, you must file DOH-4459, End of Month Covered Lives Enrollment Option. This form is also available between November 1, 2011, and December 31, 2011, on the Department´s Web site. The form must be postmarked no later than December 31, 2011.

With either filing method, once processed, the selection of this option becomes effective for the upcoming calendar year, and will remain in effect for the entire year. You are then bound to establish all your covered lives enrollment obligations as of the last day of the month for all coverages for which a covered lives obligation is due.

If you wish to continue to establish your enrollment obligations on membership during all or any portion of the month, do not select this option. Your enrollment obligation will continue to be based on membership during all or any part of the month.

Please note that choosing this option still requires you to reconcile each month to your actual enrollment counts and report all retroactive adjustments for previous periods by utilizing the Prior Period Adjustment lines on your PGP report. However, the retroactive adjustment should reflect only those individual or family units on the membership rolls as of the last day of the month for which an adjustment is needed.

If you enlist a Third Party Administrator (TPA) to fulfill your HCRA reporting obligations, you must notify your TPA regarding the selection of this option before the January monthly PGP report due date.

As always, all PGP report submissions are subject to audit by the Department. Upon audit, you will be required to provide sufficient documentation to support the accuracy of the reports submitted and payments made.

If you have any questions concerning the foregoing, please contact the Office of Pool Administration at (315) 671-3800.

Sincerely,

John E. Ulberg, Jr.
Director
Division of Health Care Financing