NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES
Form No: WC-MCPC (Ed. 10/2018)
WORKERS’ COMPENSATION MANAGED CARE PREMIUM CREDIT PROGRAMS FILING
COMPLIANCE QUESTIONNAIRE
COMPANY
Co. File No.
Company Contact:
Phone Number:
E-Mail Address:
Instructions: All applicable items must be answered. Responses in the shaded area indicate non-compliance with
applicable requirements and statutes. Failure to complete all items, or responses in the shaded area, will result in this
filing being returned without further review.
Name of the Managed Care Organization to be utilized
Amount of Credit (can be no more than 10%)
%
A. Submission includes:
1. A copy of the Business Contract or Management Service
Agreement
YES
NO
2. Documentation of the approval of the agreement/contract
by the N.Y.S. Department of Health.
YES
NO
3. The Office of Managed Care Workers’ Compensation
Preferred Provider Organization Certificate of Authority
YES
NO
4. The New York Preferred Provider Premium Organization
Endorsement (WC 3104 03A) and/or the New York
Preferred Provider Organization Endorsement (WC 31 06
16A) (Filed with the New York Compensation Insurance
Rating Board)
YES
NO
5. Cancellation and nonrenewal guidelines in the New York
Workers’ Compensation and Employer Liability Manual
YES
NO
6. A discount that will remain in effect for no more than 4
years
YES
NO
B. MANAGED CARE ORGANIZATION/PPOs
1. The rate modification is applied on a multiplicative basis,
after the experience modification and before premium
discounts and expense fees.
YES
NO
2. The filing includes the requirements that a policyholder has
to maintain in order to remain eligible for the credit.
YES
NO
3. The filing contains an acknowledgment that any qualified
employer who agrees to participate in the program will
receive the credit.
YES
NO
4. The filing includes a list of all counties in which the credit
will be utilized.
YES
NO
5. The filing includes procedures to follow when an insured
no longer qualifies for the discount, or has misrepresented
its compliance with the managed care agreement.
YES
NO
6. The credit applies only to insureds located in those
counties certified by the Department of Health as approved
PPO service areas.
YES
NO
7. For employers with operations in counties where the
Managed Care Credit is not applicable the premium credit
is based on standard premium.
YES
NO
8. The program is retrospectively rated.
YES
NO
NOTE: For additional information refer to Circular Letter No. 18(1997) and its supplements.
