GME CLA rates and percentage surcharges vary between eight regions, and the applicable rate depends on where the covered individual resides or receives hospital care within the state. In 2022, the Ministry of Health applied Additional monthly CLA rate For the months of April-December.
Electing financiers. New York City continues to have the highest annual CLA for select payers: $200.60 per person with self-only coverage and $661.97 per person with family coverage. The minimum CLA application ($10.59 for self only, $34.95 for family) continues in the 11-county Utica/Watertown area. All eight regions experienced an average increase of previous levels.
the unelected. GME percentage surcharges paid by non-selected directly to government hospitals where covered individuals incur certain expenses that also vary by region. For example, the 2023 GME overcharge over specified expenses is 27.28% for New York City Hospital and is 2.25% for the Utica/Watertown area. This surcharge has not increased for the percentage of non-GME-specified payers since 2006.
As a result, a covered, self-covered-only individual living in New York City would cost an elected payer $200.60 for the year, regardless of whether or not that person incurs any in-state hospital fees. Elective and non-elected payers who are not covered by New York State residents do not owe any CLA. However, if the covered individual incurs a $100,000 bill for New York City hospital services subject to the GME surcharge, the unspecified payer will owe a total of $127,280—less any applicable cost-sharing—for that hospital bill with the surcharge.
Conversely, the payer elected in the example above does not owe any additional GME percentage charges, but instead owes CLA only to the extent that the payer has covered New York State residents. Because select payers with no covered employees who are New York residents do not owe the CLA, out-of-state plan sponsors who do not have (or a few) New York residents may want to consider becoming an elective payer to avoid unspecified and unexpected GME surcharges and reduce the indigent care surcharges described below.
Under the HCRA, health claim payers—including self-funded health plans—must pay an additional cost for indigent care for New York Hospital’s inpatient and outpatient services, comprehensive diagnostic and treatment centers, and ambulatory surgery centers. This additional cost applies even if the patient is a resident or the employer or group health plan is based out of state.
For services provided by From April 1, 2009 until the end of 2023The surcharge is 9.63% for elect payers who pay these expenses to the Public Goods Fund and an additional 28.27% (or a total of 37.9%) for non-elect payers who pay the surcharge to service providers. If the services are also covered by the GME CLA, this will be added to the bill for the unspecified payer. So a New York City hospital bill of $100,000 with a surcharge of 27.28% GME plus a 37.9% indigent care fee could result in a total bill of $165,180 for hospital services and both surcharges.
While dental coverage is considered “health coverage” under the HCRA, the CLA and surcharges only apply to services received at an HCRA-designated facility, such as a New York hospital or surgical center. Dental procedures performed in a dentist’s office are usually exempt from the GME CLA fee/percentage and supplementary fee for the care of the indigent. So a typical employer-sponsored dental plan usually does not result in HCRA costs.
However, as noted in Frequently asked questions about NY HCRA (unchanged since last year), when a HCRA-designated provider performs dental services, additional GME and indigent fees apply at rates based on the third-party payer’s election status. Designated providers include general hospitals, extension clinics, and diagnostic and treatment centers that provide comprehensive primary care or ambulatory surgical services.
While most dental care typically occurs in independent dentists’ offices, a dentist office owned by a HCRA-designated facility can be considered an extension clinic, subject to HCRA. Several databases maintained by the Ministry of Health (current as of December 1, 2022) – eg Hospital counseling clinicsAnd Comprehensive clinics And Counseling clinics for diagnostic and treatment centers It includes many dental facilities.
Keep in mind that HCRA only applies to fully insured, self-financed medical and dental plans. that Instructions You confirm that HCRA rates do not apply to health flexible spending arrangements, health reimbursement arrangements, or health savings accounts.
MoH-designated payers have the option to submit monthly or annual reports and payments on the Public Goods Pool. Monthly Provider reports and payments must be received by the Department of Health no later than the 30th day after the end of the covered month (or the next business day if the 30th is a weekend or holiday). Annual reports and payments for the previous covered year, also subject to weekends and holidays, must be received by the Department of Health by January 30 (that is, by January 30, 2024, for the 2023 covered year). Late reports and payments will result in penalties and interest. This deposit obligation exists even if the selected payer has no activity to report.
Even if no employees reside in New York, the additional fee applies to any health or dental services provided at an HCRA-designated facility.
Example. Jim and Joyce’s employer, STU Corporation, is an unselected payer. Jim resides in Connecticut and regularly visits friends and family in New York. Joyce resides in Georgia but visits New York City regularly for vacation. Any urgent care Jim or Joyce received while in New York could generate additional fees much higher than what the STU would pay as an election payment.
Because of the significant impact that HCRA surcharges can have on unspecified payers, self-funded plan sponsors with networks extending into New York—or with large numbers of participants residing in neighboring states—may wish to review their election status with the plan administrator.