New York Announces 2023 HCRA Rating Rates for Covered Lives

GME CLA rates and surcharge percentages vary between eight regions, and the applicable rate depends on where the insured person resides or is being treated at a government hospital. In 2022, DOH applied a small, additional monthly CLA rate for the months of April through December.

select payer. New York City continues to have the highest annual CLA for payer choice: $200.60 per person with self-insurance and $661.97 per person with family insurance. The lowest CLA ($10.59 for self-catering, $34.95 for families) still applies in the 11-county Utica/Watertown area. All eight regions saw rates increase from previous levels.

Don’t choose payer. The percentage of GME surcharge that non-voting payers pay directly to government hospitals where insured individuals pay certain costs also varies by region. For example, the 2023 GME percentage surcharge for certain expenses peaks at 27.28% for a hospital in New York City and troughs at 2.25% in the Utica/Watertown area. These percentage GME surcharges for non-voting payers have not increased since 2006.

As a result, a self-insured insured person residing in New York City costs an elective payer $200.60 for the year, regardless of whether that person incurs no or significant state hospital fees. Dialing and non-dialing payers without insured New York State residents do not owe a CLA. However, if an insured person is due a bill for US$100,000 for hospital services in New York City that are subject to the GME Percentage Surcharge, a non-voting payer owes a total of US$127,280, less any participant co-payment, for them hospital bill with the surcharge.

Conversely, in the above example, a dialing payer does not owe a percentage GME surcharge, but instead owes a CLA only to the extent that the payer covered New York State residents. Because election payers with no insured employees residing in New York do not owe a collective bargaining agreement, out-of-state plan sponsors with no (or few) insured New York residents should consider becoming election payers to avoid uncapped and unpredictable GME percentage surcharges and reduce the below described needy care allowance.

Under the HCRA, payers of health insurance claims — including self-funded health plans — are also required to pay a needy patient supplement for inpatient and outpatient services at New York City hospitals, comprehensive diagnosis and treatment centers, and outpatient surgery centers. This surcharge applies even if the patient is a resident or the employer or group health insurance plan is based out of state.

For services provided from April 1, 2009 through the end of 2023, the surcharge is 9.63% for elective payers who pay those costs to the commons pool, and an additional 28.27% (or 37.9% total) for those who do not choosing payers who pay the surcharge to the provider. If services are also covered by the GME-GAV, these are added to the invoice of the non-choosing payer. So a hospital bill in New York City of $100,000 with a GME supplement of 27.28% plus a needy supplement of 37.9% could result in a total bill of $165,180 for the hospital services and both supplements.

While dental care is considered “health insurance” under the HCRA, the CLA and supplements apply only to services provided at an HCRA-designated facility, such as a dental clinic. B. a hospital or surgical center in New York. Dental treatments that take place in a dental practice are usually exempt from the GME GAV/percentage surcharge and needy surcharge. So, a typical employer-sponsored, stand-alone dental plan typically does not incur HCRA costs.

However, as noted in the NY HCRA FAQ (unchanged since last year), when an HCRA-designated provider is providing dental services, the GME and needy supplements apply at rates based on the elective status of the third-party payer. Designated providers include general hospitals, their consulting clinics, and diagnostic and treatment centers that provide comprehensive primary care or outpatient surgical services.

While most dental care typically occurs in stand-alone dental offices, a dental office owned by an HCRA-designated entity may be considered an affiliate clinic subject to the HCRA. Various databases maintained by the DOH (as of December 1, 2022) — such as the Extension Clinics for Hospitals, Comprehensive Clinics, and Extension Clinics for Diagnostic & Treatment Centers — encompass numerous dental facilities.

Keep in mind that the HCRA only applies to fully insured and self-funded medical and dental plans. A frequently asked question confirms that HCRA rates do not apply to Flexible Health Expense Arrangements, Medical Reimbursement Arrangements, or Health Savings Accounts.

Polling payers designated by the DOH have the option to submit either monthly or annual Public Goods Pool reports and payments. Monthly reporters’ reports and payments must be received by DOH no later than the 30th day after the end of the covered month (or the next business day if the 30th day is a weekend or holiday). Annual report reports and payments for the previous Covered Year, again excluding weekends and holidays, must be received by DOH by January 30 (ie, by January 30, 2024 for the 2023 Covered Year). Late reports and payments will incur penalties and interest. This obligation to report also applies if the voter has no activity to report.

Even if no employees reside in New York, the supplements apply to any health or dental care provided at an HCRA-designated facility.

example. Jim and Joyce’s employer, STU Co., is an unelectable payer. Jim lives in Connecticut and regularly visits friends and family in New York. Joyce lives in Georgia but regularly visits New York City for vacations. Any urgent care received by Jim or Joyce while in New York could result in significantly higher surcharges than STU Co. would pay as a select payer.

Because of the significant impact HCRA surcharges can have on unelected payers, self-funded plan sponsors with networks extending into New York—or with significant numbers of participants residing in neighboring states—should verify their electoral status with the plan administrator.