The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
ANDREW M. CUOMO
Governor
LOLA W. BRABHAM
Commissioner
PE20-27
TO: Participating Employer Health Benefit Administrators
FROM: Employee Benefits Division
SUBJECT: Health Benefit Administrator Responsibilities
DATE: November 19, 2020
This memo serves to delineate the responsibilities of an agency Health Benefit Administrator (HBA) and the roles of the Employee Benefits Division (EBD). EBD provides guidance and assists HBAs with questions pertaining to employees’ health insurance enrollment and eligibility rules under the New York State Health Insurance Program (NYSHIP). To uphold these responsibilities, HBAs must have access to all materials available on NYSHIP Online and HBA Online. Access to these websites can be requested through the agency Data Access Officer (DAO). Please refer to HBA Memo NY24-14/PE24-10/PA24-09/SEHP24-09 for more information.
The Role of an HBA
There are several functions the HBA performs, including:
- Understanding NYSHIP rules and regulations and how to apply them,
- Determining an employee’s benefits eligibility,
- Ensuring that employees are properly informed of and fully understand their NYSHIP options,
- Providing enrollees and prospective enrollees their plan materials by either directing them to NYSHIP Online or ordering copies of the appropriate NYSHIP publications from HBA Online.
- Informing employees about what is required to enroll themselves and their eligible dependents in NYSHIP coverage and to make coverage changes, if necessary. This includes confirming the completion of the appropriate forms and advising which proofs are needed. HBAs review applications of enrollment and/or changes along with all supporting documentation timely.
- Processing enrollments and enrollment changes through NYBEAS in a timely manner
- Providing your agency’s NYBEAS Users training and continued guidance in their processing of transactions
- Ensuring enrollees are notified immediately of accepted or denied applications
- Assisting enrollees in understanding their health insurance deductions.
- Determining eligibility for retiree NYSHIP coverage and if/when Medicare will be primary to NYSHIP.
Important Communications
HBAs are expected to read all communications and updates issued by EBD in order to perform their duties and ensure your agency’s NYBEAS Users are provided with and understand all pertinent information to accomplish their assigned duties. This includes, but is not limited to, regular review of:
- HBA Online
- HBA Memos
- Policy Memo
- Policy Memos
- System Announcements
- NYSHIP Online
- Prior to Contacting the HBA Help Line Check List
Access to NYBEAS
The HBA should inform the DAOs if they are no longer the HBA or if additions or changes are required to NYBEAS access for themselves or their staff. Although it is ultimately the responsibility of the DAO to request changes to an agency’s access to NYBEAS.
New for HBAs
NYBEAS Users who are not designated as an agency HBA must seek assistance directly from the agency HBA. NYBEAS Users contacting the HBA Help Line, will be referred to their HBA for assistance.
EBD has created a list of reference items that addresses common HBA issues and concerns. This check list is another tool HBAs must utilize to assist themselves and it answers most questions that arise. In many instances, these resources will obviate the need to call the HBA Help Line. A copy of the Prior to Contacting the HBA Help Line Check List is attached. NYBEAS Users may use the checklist as a guideline but must consult the HBA for assistance.
Furthermore, EBD is now requiring all NYBEAS Users, including HBAs, to acknowledge their role and their duties recorded within this memo; regularly review of EBD communications and updates; and to adhere to all privacy and HIPAA regulations in the application of their duties, most particularly for the privilege of NYBEAS access and use. HBAs and agency NYBEAS Users must read and confirm their understanding as stipulated in the attached Confidentiality Agreement and Attestation Form by signing and returning the form to EBD. HBAs who do not return the form by December 18, 2020 may have their NYBEAS permissions revoked and will be required to request access through their DAO once again.
One form per agency must be submitted and contain the names and signatures from all NYBEAS Users including the HBA. Return the completed form to EBD by email to cs.sm.dao-hba@cs.ny.gov and in the subject line reference the agency code, agency name, and the word “agreement”. Please add additional signature lines and/or pages as needed.
EBD’s Role in Assisting HBAs
EBD is here to develop an HBA’s skills by making self-help materials accessible on NYBEAS, HBA Online, and NYSHIP Online, and explaining these materials to HBAs when appropriate. When calling the HBA Help Line, an HBA should have NYBEAS, HBA Online, and NYSHIP Online open. Depending on your inquiry, EBD staff may ask you to access these materials during the call to ensure you have appropriate access to the information in the future.
EBD also aids HBAs in making determinations of eligibility in unique circumstances not identified in the NYSHIP rules and regulations or Plan materials; provides clarification of rules and regulations; and assists in the review of escalated cases. EBD staff reviews HBA and enrollee correspondence, correction requests, quality control reports, worklists, special projects, and may reach out to HBAs to gather more detailed information when necessary.
EBD staff receives calls from HBAs throughout New York State, as well as from individuals on a leave of absence or no longer employed by New York State (Retirees, Vestees, Dependent Survivors and COBRA/Young Adult Option enrollees).
Former Employees Requiring Assistance
The role of the HBA is transferred to EBD staff when an enrollee leaves State service. To maintain HIPAA compliance standards, former employees should therefore be directed to contact the EBD toll free line at 1-800-833-4344 for assistance.
EBD has designated units who handle the non-employee population (Retiree, COBRA, etc.). This includes Rehired Retirees who are continuing their health insurance coverage as a Retiree and Active employees calling on behalf of their dependent enrolling in COBRA.