For clients going into a self insured plan for the first time, this question always comes up. The employer always has the option to participate in the pool or not but we always encourage them to participate for their own protection. This only comes into play when a member of a group seeks or gets medical treatment in New York
For groups who do not elect into the Pool
If there are New York state residents that incur in-patient claims in New York there is an alternative covered lives payment based on the resident’s location and this can be up to an additional 27.28% of claims if not more.
The purpose of the New York Pool Election forms is the protect you-the client in the event an employee travels to New York and requires medical treatment. If documents are not filed with the New York Pool, you as a client can be penalized for medical claims. Any penalties or surcharges will not be cover by your Stop Loss.
Electing to participate
The employer pays 9.63% surcharge on each applicable claim to the Pool monthly or annually, depending on their election as well as the covered lives assessment determined by an employee’s residence in the State of NY from an employer census.
Not electing to participate
The provider bills the employer 28.27% penalty surcharge on each claim plus the surcharge of 9.63%. (provider keeps 28.27% and the surcharge of 9.63% pays to the Public Goods Pool)
In summary your stop loss will not cover excess claim charges without participating in the pool in advance. Click Here to Download the AFA-HCRA
As always please contact your Total Benefit Solutions, Inc Group Account Manager at (215)355-2121 if you have questions about this bulleting or health insurance forms.