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Health Care Reform Act

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You are Here: Home Page > Health Care Reform Act (HCRA) > New York State Health Care Reform Act (HCRA)  

New York State Health Care Reform Act (HCRA)

• Cross-Reference Index for HCRA Forms (PDF, 23KB, 1pg.)
• Reporting Forms and Instructions

Payor

• DOH-4402 Payor Status Change (PDF, 40KB, 2pg.)
• DOH-4403 TPA/ASO Status Change (PDF, 33KB, 2pg.)
• DOH-4404 Request to Rescind Election Status (PDF, 43KB, 2pg.)
• DOH-4406 Merger-Acquisition (PDF, 40KB, 2pg.)
• DOH-4409 Payor/TPA/ASO Change of Information (PDF, 30KB, 1pg.)

Third Party Administrator (TPA)/Adminstrative Services Only (ASO)

• DOH-4401 TPA/ASO Client List Addendum - Additions (PDF, 31KB, 2pg.)
• DOH-4411 TPA/ASO Client List Addendum - Deletions (PDF, 32KB, 2pg.)
• DOH-4404 Request to Rescind Election Status (PDF, 43KB, 2pg.)
• DOH-4409 Payor/TPA/ASO Change of Information (PDF, 30KB, 1pg.)

Provider

• DOH-4405 Provider Election For Medicaid Withholding (PDF, 26KB, 1pg.) or Report of Medical Assistance Surcharge Payments for Non-Electing Providers (PDF, 38KB, 3pg.)
• DOH-4264 Electronic Filing User ID Application (PDF, 37KB, 2pg.)
• DOH-4407 Provider Name and Address Change (PDF, 26KB, 1pg.)
• DOH-4408 Provider Status Change (PDF, 38KB, 2pg.)

Election Documents

• DOH-4399 Payor Election Application (PDF, 87KB, 7pg.) and DOH-4264 Electronic Filing User ID Application (PDF, 37KB, 2pg.)
• DOH-4400 TPA/ASO Election Application (PDF, 50KB, 6pg) and DOH-4264 Electronic Filing User ID Application (PDF, 37KB, 2pg.)

Filing Options (Open Enrollment - November 1 through December 31)

1. DOH-4486 Payor Change of Filing Status from Annual to Monthly (PDF, 21KB, 1pg.)
   Annual filers may switch to be monthly filers for the upcoming calendar year.
2. DOH-4459 End of Month Covered Lives Enrollment Option (PDF, 99KB, 1pg.)
   Monthly filers have the option of establishing their covered lives enrollment obligations as of the last day of the month.

Note: For immediate enrollment, Payors with a User ID and Password may file these options electronically through the Payor Options section located on the New York State Office of Pool Administration's web site: www.hcrapools.org/hcra_index.cfm.
If you do not have a User ID and Password you must submit hardcopy form(s) and wait for confirmation of enrollment.