New York Health Care Reform Act

The forms are available on the NYHRCA website.

To be an electing payor, you must complete DOH-4399 (Payer Election Application) and DOH-4264 (Electronic User ID Application).

If you already filed an election, but changed your third-party administrator, you must complete DOH-4403 (Third Party Administrator or Administrative Services Only Status Change).

Submit a DOH-4402 (Payor Status Change) form if you become fully insured, close your self-funded account, go out of business, or file for bankruptcy.

Submit a DOH-4406 (Merger Acquisition) form if your company has been acquired and/or merged with another payor.

The 1996 NYHCRA provided for two levies:

1. A surcharge on defined claims for indigent care and health care initiatives.
2. An assessment fee for GME (Graduate Medical Education), based on New York state residency.

The indigent care surcharge is a levy based on a state-determined percentage rate of payments for defined claims to New York state providers. The percentage rate is periodically re-evaluated and revised.

The GME assessment is based on New York State residency and is applicable to all health insurance plans, insured and self-funded.

The NYHCRA is not preempted by the Employee Retirement Income Security Act of 1974, or ERISA for short. Under the NYHCRA, entities that pay on behalf of their plan participants for health services delivered by certain designated providers in New York have a choice whether to file an election application to make public goods surcharge payments at reduced rate levels directly to the OPA or pay surcharges directly to designated providers at substantially higher rates. Entities that file this election are required to file NYPGP reports electronically with the state of New York, regardless of whether any payments are due.

You can find more information at: https://www.health.ny.gov/regulations/hcra/

Yes. BlueCard is the system that allows all Blue Cross and Blue Shield licensees to handle fees/payments for the NYHCRA and the NYPGP.

The NYHCRA filing requirements for BCBSND and its self-funded groups are affected by a special agreement between the DOH and Anthem BCBS. Anthem BCBS acts as a conduit for payment of claims in New York through BlueCard for BCBSND and its self-funded groups. Anthem BCBS is considered the payor of claim and, as payor, is obligated to remit NYPGP reports, surcharge payments and covered lives, if applicable, to the OPA in New York. Anthem BCBS files the NYPGP reports and submits the surcharge under their election and then bills BCBSND.

As a TPA (Third Party Administrator), BCBSND pays the surcharge and covered lives assessment to Anthem BCBS on behalf of its self-funded groups.

The covered lives assessment is billed as a line item on the group’s monthly invoice. The indigent care surcharge is automatically included on any applicable claim that is billed to the group through BlueCard.

Anthem BCBS’s election into the NYPGP protect BCBSND and its self-funded groups from paying a higher surcharge incurred in New York.

No. BCBSND handles the payments and reporting for claims from providers within the BlueCard system through Anthem BCBS. Most claims are submitted through BlueCard, but some member-submitted claims may be submitted outside of it.

Members can use the Find a Doctor tool to see if that provider is in the general directory. 

Surcharges are for claims that process through BlueCard and covered lives assessments are paid regardless of whether the group has opted in. It is not necessary to opt in for this process to take place.

For claims that fall outside of BlueCard, the payor of the claim (e.g., the self-funded group) must have their own election on file to be able to pay the lower surcharge rate.

If the group has an election on file with the state of New York, BCBSND will submit reporting to the state of New York, consistent with that election. The election would protect the group from paying a higher indigent surcharge in the event the group incurred a claim outside of BlueCard. Most claims are submitted through BlueCard, but some member-submitted claims may be submitted outside of BlueCard.

BCBSND’s reporting services are included within the group’s standard administrative fee.

If you don’t want to opt in, you don’t need to fill out any forms.

You’re responsible for ensuring all forms are filed. Self-funded groups are responsible for notifying OPA regarding changes or updates to their TPA designation or funding status (DOH-4403). BCBSND would continue to file for the group from the master client list provided by the OPA, or our Sales department is made aware of the group’s termination. If the group does not change their TPA from BCBSND to their new carrier, the group could be assessed penalties if they are incurring claims and not paying appropriate surcharges and assessments.

BCBSND does not proactively send out any communication of filing requirements and forms to be completed.

Self-funded groups are responsible for notifying the OPA regarding changes or updates to their TPA designation or funding status.

BCBSND is not notified by the NYPGP when changes are made to a group’s filing status. BCBSND uses a monthly client list to look for applicable changes or updates; however, it is recommended groups either complete the form themselves, or reach out to their account manager for assistance. BCBSND cannot complete the forms on the group’s behalf.

Groups that are new electors to the pool are required to file reports and make payments to the pool on a monthly basis, during the first 12 months. After a group has been in the pool for at least 12 months, the state of New York will make an annual determination on whether the group will remain a monthly filer or become an annual filer based on the amount of tax paid to the pool in the prior year. Groups the state designates as annual filers will receive a notice from the pool in November indicating the group has been designated an annual filer for the next year and providing an opportunity for the group to elect to remain a monthly filer. A group that does not want to be an annual filer must complete the form provided by the state and return it to the pool, as indicated in the annual filer notice letter.

Form 4402 is only used when a group is no longer self-funded or no longer in business. All patient surcharge fees will be paid through BlueCard for in network serices and a covered lives assessment fee will not apply. 

Penalties from the NYHCRA may result in failure to notify the OPA of changes.

Contact your BCBSND account manager  for help.