Dear Payor: Covered Lives Enrollment Option
December 3, 2008
Re: New York State Health Care Reform Acts of 1996 and 2000 (HCRA)
Effective January 1, 2009, Section 2807-t 4(f) of the Public Health Law (PHL), 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 2009 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.
Payors choosing to establish their covered lives obligations as of the last day of the month must file the enclosed DOH-4459 with the Office of Pool Administration, postmarked no later than December 31, 2008. This form, once processed, becomes effective for the 2009 calendar year and will remain in effect for the entire year. A new DOH-4459 must be filed by December 31 of each subsequent year to become effective for the upcoming calendar year. Please note that submission of the DOH-4459 binds you 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 file this form.
Further, 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 2009 report due date of March 2, 2009.
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 will 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.
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.
John E. Ulberg, Jr.
Division of Health Care Financing