Eligibility Notification

October 31, 2017

Dear Payor:

Re: New York Health Care Reform Act of 2000 (HCRA)


This notice is being sent to you because your organization: 1) is a payor of health care services, 2) has filed an election application to pay certain health care services surcharges directly to the HCRA Public Goods Pools, and, 3) has been deemed eligible to be an annual filer, rather than a monthly filer, for the January 1, 2018 through December 31, 2018 reporting period based on the criteria below. If you use a third party administrator (TPA) for claims processing and your TPA files Public Goods Pool reports on your behalf, please advise your TPA that you have received this notice.

HCRA 2000 provides that the Commissioner may permit payors, who have at least one full year of pool payment experience and whose annual liability is not expected to exceed $25,000, to submit Public Goods Pool reports and related surcharge and covered lives assessment obligations on an annual basis. The Department has set the following criteria for payors to be eligible for annual filing for 2018:

  1. A payor´s election must have been effective on or before July 1, 2016;
  2. A payor must have filed at least twelve monthly reports through the June 2017 report period; and
  3. A payor´s average annual pool payment liability must not exceed $25,000 based on reports filed through the above referenced period.

You do not need to respond to this notification if you decide to remain an annual filer. However, if you prefer to change your filing status from annual to monthly for the aforementioned period, you must notify the Office of Pool Administration (OPA) by either:

  • Electronically submitting to be a monthly filer by going to the OPA´s Web site at www.hcrapools.org, and logging onto the electronic application, "Payor Monthly Options – Monthly Filing Reporting Option". This application can be accessed with your User ID/Password from November 1, 2017 through December 31, 2017.. If you do not have a User ID/Password on file, we encourage you to complete the DOH–4264, Electronic Filing User ID Application which can be found on the OPA´s Web site. Please note that the payor, not the payor´s TPA, is responsible for electronically choosing to be a monthly filer.


  • Submitting the hardcopy DOH–4486, Change in Payor Filing Status form, by December 31, 2017, to the OPA at the address indicated on the form. The form will be available on the Department´s Web site at www.health.ny.gov/regulations/hcra/forms.htm, from November 3, 2017 through December 31, 2017, and must be endorsed by the payor, not the payor´s TPA.

Additionally, if you choose to become a monthly filer for 2018, you also have the option to establish your covered lives enrollment obligations for the 2018 calendar year on membership units enrolled as of the last day of the month. To choose this option, you must either submit the hardcopy DOH–4459, Covered Lives Enrollment Option form, by December 31, 2017, or go to the OPA´s Web site and logon to the application, "Payor Monthly Options – Covered Lives Enrollment Option". The hardcopy form and the electronic application will be available in the same manner as described above for the DOH–4486.

If you have changed TPAs or had a change of payor status, the forms that must be used to report such occurrences are available on the Department´s Web site. Please note that a payor´s change of TPAs or change of payor status (e.g. changing from self–insured to fully insured) during 2018 does not change a payor´s filing designation. A payor who is designated as a 2018 annual filer will remain an annual filer, subject to the annual reporting requirements prescribed in this notice, for the entire January 1, 2018 through December 31, 2018 reporting period. Consequently, each TPA filing a 2018 report on behalf of such payor is required to submit an annual report. Therefore, if an annual report is not filed, the payor will be considered delinquent for the entire annual reporting period, even if one or more monthly reports may have been filed.

Beginning February 2, 2018, each payor´s final 2018 filing designation will be noted on the Elector List which is posted each month to our Web site. A current year filing designation column will denote the Department´s final determination.

If you use a TPA, you should contact them directly with any questions you may have regarding this notice. Payors having questions that are not represented by a TPA should contact the Office of Pool Administration at (315) 671–3800.


Donna Cater
Deputy Director
Division of Finance and Rate Setting
Office of Health Insurance Programs