New York State Health Care Reform Act (HCRA)
NOTICE TO ELECTING PAYORS REGARDING ACCEPTABLE METHODS OF CALCULATING COVERED LIVES ASSESSMENTS WHEN AN INDIVIDUAL/FAMILY UNIT SWITCHES REGIONS WITHIN A REPORTING MONTH
Section 2807-t (5)(a) of the Public Health Law requires remittance of the appropriate monthly covered lives assessment amount for each individual and each family unit appearing on the membership roles of a specified third party payor during any part of a given month. This notice is to provide information on the acceptable methods of calculating a payor's covered lives assessment liability for those individual/family units that switch covered lives regions within a reporting month.
Example: An individual lives in the New York City region from January 1st - 16th and then moves to the Northern Metro region on January 17th.
Payors can choose one of the following options when calculating their liability for that month:
Calculate based on their residency at the beginning of the month (New York City)
Calculate based on their residency at the end of the month (Northern Metro)
Prorate based on number of days in each region. (16/31 days New York City, reported as .52 on report) and (15/31 days Northern Metro, reported as .48 on report)
Please note that, regardless of which option is utilized to calculate a payor's covered lives liability, the method chosen must be consistently applied throughout an annual assessment period.
For audit verification purposes, electing payors are required to maintain the source records generated by supporting information systems, financial accounting records, relevant correspondence and the addresses and dates of coverage for all individuals and family units, as defined by paragraphs (a) and (b) of subdivision one of PHL section 2807-t, and such other records as may be required to prove compliance with, and to support submitted reports and covered lives liability payments. Access to this data and documentation by the State, or it's contracted agent, is required pursuant to PHL section 2807-t (3)(a) and the payor's election application agreement.