Skip to main content

Policy/Memo 80r1

Number: Policy Memo 80r1
Date Issued: December 21, 1995
Date Revised: July 28, 2017
Policy File Ref: A600
Subject: PA and PE Claims Reports

PURPOSE:

Determine the minimum number of enrollees a PA or PE must have before EBD will release claims experience to the agency.

Background:

Section 162(9) of Civil Service Law requires the Department to provide participating agencies and participating employers a report “which contains data relating to the use of benefits by persons covered under the plan by such employer. Such report shall include: premiums paid by month for each month covered in the report and paid claims by month for the following categories of services: inpatient hospital, outpatient hospital, in network medical, out of network medical, prescription drugs, and treatment of behavioral conditions, each reported separately.” Section 162(9) also stipulates that “such report shall also contain claims information for individual claimants for claims in excess of fifty thousand dollars that were paid in any of the months covered by the report.”

When an agency has a limited number of enrollees, it is possible that the claims information could be associated with an individual enrollee, thereby depriving the enrollee of his/her right to privacy concerning medical claims. While EBD is cognizant of this section of Civil Service Law, it is also aware of various privacy protections included in federal law guaranteeing enrollees’ privacy.

Policy:

Aggregate claims experience shall not be released if the PA or PE has an enrollment of fewer than eleven individuals for any month covered by the report. In addition, claims information for individual claimants for claims in excess of fifty thousand dollars shall be excluded if there were fewer than eleven such individuals for the months covered by the report.