The GME CLA fees and surcharge percentages vary across the eight regions, and the applicable fees vary depending on where the covered individual resides or is being treated at a hospital within the state. In 2022, DOH applied a small additional monthly CLA rate for his April-December months.
Election of Payers. New York City continues to have the highest annual CLAs for choosing payers. $200.60 per individual for self-only coverage and $661.97 per individual for family coverage. In the 11-county Utica/Watertown area, CLA minimums ($10.59 for self-only and $34.95 for family) continue to apply. All eight regions saw rates increase from previous levels.
Do not select a payer. The GME Percentage surcharge paid by non-selected payers directly to hospitals in the state where covered individuals incur certain costs also varies by region. For example, his 2023 GME percentage surcharge on certain expenses reaches the highest in New York City hospitals at 27.28% and the lowest in the Utica/Watertown area at 2.25%. These non-select payer GME percentage surcharges have not increased since 2006.
As a result, self-only covered individuals residing in New York City will not be able to pay their chosen payments, regardless of whether that person incurs no or a large amount of in-state hospital costs. costs $200.60 per year to Selected and non-selected payers who are not eligible New York residents have no CLA obligations. However, if a Covered Individual incurs a $100,000 bill that is subject to the GME Percentage surcharge for hospital services in New York City, the non-selected payer will pay a total of $127,280 (including the applicable Participant’s share of the cost). deducted) must be paid with the hospital bill and surcharges.
Conversely, the payer selected in the example above is not obligated to pay the GME percentage surcharge, but instead is obligated to pay the CLA only to the extent the payer covers New York residents. Out-of-state plan sponsors with no (or very few) New York resident insured persons are eligible for uncapped projections because elective payers who do not have New York resident insured employees do not have CLA obligations. To avoid the impossible GME percentage surcharge, we encourage you to consider becoming a choice payer. It also reduces the Poor Care surcharges described below.
Under the HCRA, health payers (including self-financed health plans) provide inpatient and outpatient services in New York hospitals, comprehensive diagnostic and treatment centers, and ambulatory surgical centers to help the poor. You will also have to pay a medical surcharge. This surcharge applies even if the patient resides or has employer or group health insurance out of state.
The surcharge for services provided from 1 April 2009 to the end of 2023 is 9.63% for elective payers who pay this cost to the public goods pool and an additional 28.27% for non-selective payers. (or 37.9% total). Additional charges to providers. If the service is also covered by his GME CLA, this will be added to the non-selected payer’s invoice. Thus, a New York City hospital bill of $100,000 with a 27.28% GME percentage surcharge and a 37.9% poverty care surcharge could result in a total bill of $165,180 for hospital services and both surcharges. There is a nature.
Under the HCRA, dental insurance is considered “health insurance,” but the CLA and surcharges apply only to services received at HCRA-designated facilities, such as New York hospitals and surgical centers. Dental procedures performed at a dental office are generally exempt from the GME CLA/Percentage Surcharge and the Poor Care Surcharge. As such, typical employer-sponsored stand-alone dental plans typically do not incur HCRA costs.
However, as noted in the NY HCRA FAQ (unchanged from last year), when dental services are provided by HCRA designated providers, GME and poor surcharges are subject to third party payer choice status. applied at a rate based on Designated providers include general hospitals, their extension clinics, and diagnostic and treatment centers that provide comprehensive primary care or ambulatory surgery services.
Although most dental care is typically performed in independent dental offices, dental offices owned by HCRA-designated facilities may be considered extended clinics covered by the HCRA. The various databases maintained by the DOH (as of December 1, 2022) – extension clinics for hospitals, general clinics, extension clinics for diagnostic and treatment centers, etc. – contain a large number of dental facilities.
Please note that HCRA applies only to fully insured and self-funded medical and dental plans. The FAQ confirms that the HCRA rate does not apply to medical flexible spending arrangements, medical reimbursement arrangements, or health savings accounts.
Select payers designated by the DOH have the option to submit monthly or annual public goods pool reports and payments. A monthly filer’s report and payment must be received by her DOH within 30 days (or the next business day if the 30th falls on a weekend or holiday) after the end of the applicable month. The annual filer’s report and payment for the previous covered year, covered by weekends and holidays, must be received by DOH by January 30 (i.e. for her 2023 to be covered). he by January 30, 2024). Late reporting and payment will result in fines and interest. This filing obligation exists even if the selected payer has no activity to report.
Additional fees apply to all health or dental services provided at HCRA-designated facilities, even if the employee does not live in New York.
exampleJim and Joyce’s employer, STU Co., is a non-select payer. Jim lives in Connecticut and regularly visits friends and family in New York. Joyce lives in Georgia, but she regularly visits New York City on vacation. Any emergency treatment received by Jim or Joyce while in New York could result in significantly higher additional charges than STU Co. would pay as the payer of choice.
HCRA surcharges can have a significant impact on non-selected payers, so for self-financed plans whose networks extend to New York or where many participants reside in neighboring states. Sponsors are encouraged to verify their selection with the plan administrator.
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