CM-11-12-251Item Caption:
CfVl-lJ-12-1S1
RECEIVED
DEC 147011
City Manager Approval Form
Consider executing a Health Care Reform Act - Public Goods Pool Monthly Reporting Option Agreement
with the New York State Department of Health
Approval Date: 12/16/2011
Department Name: Human Resources Department
Project Manager: Karin Holland
Assigned Attorney: Contract Management Section
Item Summary:
Aetna is currently a monthly filer for all customers in New York. This form allows Aetna as the City of Round Rock Third Party
Administrator (TPA) to remain as a monthly filer for the City of Round Rock.
This form allows Aetna to provide benefits in the State of New York for any employee, dependent, or retiree who has a claim
while in the State of New York.
No. of Originals Submitted: 2
Project Name: Monthly Reporting Option for Aetna in State of New York
Cost: 0.00
Source of Funds: Select Source Fund
Source of Funds (if applicable): Select Source Fund
Account Number:
Finance Director Approval: Chem Delaney
Department Director Approval:
Date: 12/14/11
Date:
la --►U «
**Electronic signature by the Director is acceptable. Please only submit ONE approval form per item. **
CIP ✓❑ I I Budget
N/A OK
111 El
N/A OK
Purchasing
❑ El
Accounting
N/A OK
N/A O❑K
ITEMS WILL NOT BE PLACED ON THE COUNCIL OR CM AGENDA W/OUT PRIOR FINANCE AND/OR LEGAL APPROVAL
REV. 6/20/11
NEW YORK STATE DEPARTMENT OF HEALTH
Davison of Health Care Feta
Chan• e in Pa or Filin • Status
HEALTH CARE REFORM ACT - PUBLIC GOODS POOL
MONTHLY REPORTING OPTION
As an electing payor, you have been deemed eligible to be an annual Public Goods Pool tiler for the
upcoming reporting period of January 1 through December 31. However, you have the option to become
a monthly Public Goods Pool fifer.
If you choose to file monthly Public Goods Pool reports for the upcoming calendar year, you must
complete this form and retum it to the Office of Pool Administration by December 31. If you do not submit
this change in filing status, your filing status will remain as annual.
Please forward a copy of this information to your Third Party Administrator(s) or Administrative Service
Organization(s)
FEDERAL EMPLOYER
IDENTIFICATION # (FEIN):
PAYOR NAME:
ADDRESS
CONTACT PERSON
PHONE #:
EMAIL ADDRESS:
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By signature below, the aforementioned payor elects to file monthly reports and make public goods
surcharge and assessment payments directly to the Office of Pool Administration for all its coverages for
which it assumes risk for the payment of medical claims, pursuant to Sections 2807-j and 2807-t of the
Public Health Law
Signature
Date 12.'1rj-ir
If you have any questions, please call the Office of Pool Administration at (315) 671-3800. This
information should be mailed, via express or regular mail, to the appropriate address listed below
Express Mail:
Mr. Jerome Alaimo, Pool
Administrator
Office of Pool Administration
333 Buttemut Drive
Syracuse, New York 13214-1803
Regular Mail:
Mr. Jerome Alaimo, Pool
Administrator
Office of Pool Administration
P.O. Box 4757
Syracuse, New York 13221-4757
DOH - 4486 (10/2009) Page i of 1
Clm-I1-12-LSA
Nirav R. Shah, M.D., M.P.H.
Commissioner
Dear Payor:
NEW YORK
state department of
HEALTH
Re: New York Health Care Reform Act of 2000 (HCRA)
Sue Kelly
Executive Deputy Commissioner
November 1, 2011
IMPORTANT NOTE
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, 2012, through December 31, 2012, 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 2012:
1) A payor's election must have been effective on or before July 1, 2010
2) A payor must have filed at least twelve monthly reports through the June 2011 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, 2011, through December 31, 2011. 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.
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Nirav R. Shah, M.D., M.P.H.
Commissioner
Dear Chief Executive Officer:
NEW YORK
state department of
HEALTH
Sue Kelly
Executive Deputy Commissioner
November 3, 2011
IMPORTANT NOTE!
This notice is being sent to you because your organization is a payor of health care services and has
filed an election application to pay certain health care services surcharges directly to the HCRA
Public Goods Pools. If you use a third party administrator (TPA) for claims processing, we suggest
that you contacttjour TPA directly concerning any questions you may have regarding this notice.
Section 2807-t (6) of the Public Health Law (PHL) requires that prospective adjustments be
made to Professional Education Pool (PEP) covered lives assessments to reconcile PEP regional
over/under funding for a prioi period. The law specifies that such adjustments be made in "...the year
next following the calculation of the reconciliation." Since funding of the 2010 PEP is now considered
complete, the Department has finalized the level of over/under funding within each region.
Consequently, the 2012 regional covered lives assessments have been established to incorporate these
mandated revisions.
Please be reminded that Section 2807-s (2)(cXiv) of the PHL stipulates that the alternative
inpatient PEP surcharges for periods after July 1, 2007, applicable to affected non -electing third -party
payors, be established at the same regional percentage allowances calculated for the period January 1,
2006 through June 30, 2007.
The enclosed schedule provides the 2012 regional covered lives assessments and alternative
inpatient surcharges. These amounts will be reflected in the 2012 service year portion of the Payor
Report of Covered Lives Assessment and the Hospital Report of Patient Services Revenues for Inpatient
Services.
If you use a TPA, we suggest that you contact your TPA directly concerning any questions you
may have regarding this notice. Others having questions regarding the foregoing, should contact a
HCRA representative at (518) 474-1673.
Enclosure
Sincerely,
461
John E. Ulberg, Jr. /
Director
Division of Health Care Financing
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