The GME CLA charges and proportion surcharges range amongst eight areas, and the relevant fee will depend on the place the lined particular person resides or receives in-state hospital care. In 2022, DOH utilized a small, further month-to-month CLA fee for the months of April–December.
Electing payors. New York Metropolis continues to have the best annual CLA for electing payors: $200.60 per particular person with self-only protection and $661.97 per particular person with household protection. The bottom CLA ($10.59 for self-only, $34.95 for household) continues to use within the 11-county Utica/Watertown area. All eight areas noticed a fee improve from prior ranges.
Nonselecting payors. The GME proportion surcharge that nonelecting payors pay on to in-state hospitals the place lined people incur sure bills additionally varies by area. For instance, the 2023 GME proportion surcharge on specified bills reaches a excessive of 27.28% for a New York Metropolis hospital and reaches a low of two.25% within the Utica/Watertown space. These nonelecting-payor GME proportion surcharges haven’t elevated since 2006.
In consequence, a lined particular person with self-only protection who lives in New York Metropolis will value an electing payor $200.60 for the 12 months, irrespective of whether or not that particular person incurs no or vital in-state hospital prices. Electing and nonelecting payors with no lined New York state residents don’t owe any CLA. Nonetheless, if a lined particular person incurs a $100,000 invoice for New York Metropolis hospital companies topic to the GME proportion surcharge, a nonelecting payor will owe a complete of $127,280 — minus any relevant participant value sharing — for that hospital invoice with the surcharge.
Conversely, an electing payor within the above instance doesn’t owe any GME proportion surcharge, however as a substitute owes a CLA solely to the extent the payor has lined New York state residents. Since electing payors with no lined staff residing in New York don’t owe a CLA, out-of-state plan sponsors with no (or few) lined New York residents might wish to take into account turning into an electing payor to keep away from uncapped and unpredictable GME proportion surcharges and cut back the indigent care surcharge described beneath.
Beneath the HCRA, well being declare payors — together with self-funded well being plans — should additionally pay an indigent care surcharge for New York hospital inpatient and outpatient companies, complete diagnostic and therapy facilities, and ambulatory surgical procedure facilities. This surcharge applies even when the affected person resides or the employer or group well being plan is predicated out-of-state.
For companies delivered from April 1, 2009, by means of the top of 2023, the surcharge is 9.63% for electing payors that pay this expense to the Public Items Pool and a further 28.27% (or a complete of 37.9%) for nonelecting payors that pay the surcharge to suppliers. If companies are additionally lined by the GME CLA, this might be added to the nonelecting payor’s invoice. So a $100,000 New York Metropolis hospital invoice with a 27.28% GME proportion surcharge plus a 37.9% indigent care surcharge may lead to a complete invoice of $165,180 for the hospital companies and each surcharges.
Whereas dental protection is taken into account “well being protection” below the HCRA, the CLA and surcharges apply solely to companies acquired at an HCRA-designated facility, akin to a New York hospital or surgical heart. Dental procedures that happen in a dentist’s workplace are often exempt from the GME CLA/proportion surcharge and indigent care surcharge. So a typical employer-sponsored stand-alone dental plan usually doesn’t set off HCRA prices.
Nonetheless, as famous within the NY HCRA FAQs (unchanged since final 12 months), when an HCRA-designated supplier performs dental companies, the GME and indigent surcharges apply at charges based mostly on the third-party payor’s election standing. Designated suppliers embody basic hospitals, their extension clinics, and diagnostic and therapy facilities offering complete main care or ambulatory surgical companies.
Whereas most dental care sometimes happens in stand-alone dentist workplaces, a dentist workplace owned by an HCRA-designated facility may be considered as an extension clinic, topic to the HCRA. Varied DOH-maintained databases (present as of Dec. 1, 2022) — such because the Extension Clinics for Hospitals, Complete Clinics and Extension Clinics for Diagnostic & Therapy Facilities — embody quite a few dental amenities.
Remember that the HCRA solely applies to completely insured and self-funded medical and dental plans. An FAQ confirms that HCRA charges don’t apply to well being versatile spending preparations, well being reimbursement preparations or well being financial savings accounts.
DOH-designated electing payors have the choice to file both month-to-month or annual Public Items Pool reviews and funds. Month-to-month filers’ reviews and funds should be acquired by DOH no later than the thirtieth day after the lined month ends (or the subsequent enterprise day if the thirtieth day is a weekend or vacation). Annual filers’ reviews and funds for the prior lined 12 months, once more topic to weekends and holidays should be acquired by DOH by Jan. 30 (ie, by Jan. 30, 2024, for the 2023 lined 12 months). Late reviews and funds will lead to penalties and curiosity. This submitting obligation exists even when the electing payor has no exercise to report.
Even when no staff reside in New York, the surcharges apply to any well being or dental companies rendered at an HCRA-designated facility.
Instance. Jim’s and Joyce’s employer, STU Co., is a non-electing payor. Jim resides in Connecticut and repeatedly visits family and friends in New York. Joyce resides in Georgia however repeatedly visits New York Metropolis for trip. Any pressing care acquired by Jim or Joyce whereas in New York may generate considerably greater surcharges than what STU Co. would pay as an electing payor.
As a result of vital affect HCRA surcharges can have on nonelecting payors, self-funded plan sponsors with networks extending into New York — or with a big variety of contributors residing in neighboring states — might wish to evaluation their election standing with the plan administrator.