Doh 4399-2026

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The document is a Payor Election Application from the New York State Department of Health, detailing the process for payors to voluntarily elect to make public goods payments directly to the Office of Pool Administration under the Health Care Reform Act. It includes instructions for completing the application forms, required information such as effective date, federal employer identification number, payor name, and contact details. The document outlines obligations for payors regarding payment remittance, reporting requirements, and jurisdictional agreements related to public health law.

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Click ‘Get Form’ to open the DOH-4399 in the editor.
Enter the effective date of election. This should be the first day of the month following submission unless a future date is specified.
Input your Federal Employer Identification Number (FEIN). Remember, this will be published on a secure website as required by law.
Fill in the payor name, which should reflect the incorporated entity or local government.
If applicable, enter any 'doing business as' (d/b/a) names under which your entity operates.
Provide the complete address of the payor and contact details including name, phone number, and email address of a responsible person.
If using a third-party administrator (TPA), include their name and FEIN. Attach additional TPA/ASO information if necessary.
Ensure that an authorized individual signs the form to confirm compliance with all requirements outlined in the application.

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2012	4.9 Satisfied (468 Votes)

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What is the New York health care Reform Act 1996?

The HCRA fund was created to fund a set of public health care programs. HCRA was enacted in 1996 to overhaul New York States regulation of payments from insurers to health care providers and create new revenue streams to fund specific programs.

What is the New York health care Reform Act?

HCRA is a major component of New York States Health Care financing laws which governs hospital reimbursement methodologies and targets funding for a multitude of health care initiatives.

What is the health care reform?

Health reform in the US refers to the overhaul of its health care system and is frequently used interchangeably with the Affordable Care Act (ACA). Health reform includes addressing the ever- increasing costs of national health care by individuals, families, and the government.

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What is the Managed Care Reform Act in NY?

The Managed Care Reform Act (the Act), in part, amends the Insurance Law to address disclosure requirements, provider due process requirements, provider contract limitations, grievance procedure requirements and provider access and continuity of care requirements.

What is the New York Public Goods pool?

What is the pool? The New York Public Goods Pool is a fund created by the state of New York to finance health care initiatives and care for the indigent within that state. The Pool was started in 1997 and is funded by a surcharge tax on all health services rendered in the state of New York.

What is the New York health Act?

Legislation nicknamed the New York Health Act would create a universal health care system and cover all primary, preventive and specialized medical care for all New Yorkers, regardless of immigration status. The system would be funded through an income-based graduated tax based on a persons ability to pay.

What is doh 4264?

Electronic Filing User ID Application (DOH-4264)

Who pays the NY HCRA surcharge?

In these situations, responsibility for payment of the HCRA surcharge rests with the private insurance carrier, at rates based on their election status, plus if applicable, a regional GME percentage, when billed.

Doh 4399-2026

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