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.
KATHY HOCHUL
Governor
REBECCA A. CORSO
Acting Commissioner
PA22-07
PAEX22-06
TO: Health Benefits Administrators at Participating Agencies with The Empire Plan and/or the Excelsior Plan
FROM: Employee Benefits Division
SUBJECT: NYBEAS and the Hold Harmless Process
DATE: June 6, 2022
This memo is to advise you of the updated process in NYBEAS that indicates how a New York State Health Insurance Program (NYSHIP) enrollee or dependent who would typically have claims paid as Medicare primary reflects when a Hold Harmless is approved. In addition, the way your agency is billed during the Hold Harmless period is changing. These changes go into effect July 1, 2022.
When an enrollee or dependent is held harmless this means that claims are paid as NYSHIP primary instead of Medicare primary. Guidance for when someone may be held harmless is documented in Policy Memo 70r4.
Typically, when someone is considered Medicare primary, your agency is charged a premium that reflects their favorable Program experience. This is called the MediPrime rate. For enrollees and dependents who are being held harmless as a result of not having Medicare Part B coverage, you will continue to be charged the non-MediPrime rate (i.e., the Plan primary rate) for that individual until the hold harmless period is over or until the individual is enrolled in Part B (whichever one comes first).
What is New
The Medicare primacy indicator in NYBEAS will be updated to show the enrollee and/or dependent is Medicare eligible and they will be enrolled in the Empire Plan Medicare Rx prescription drug program.
However, the coverage description (Covrg Desc) will be changed to reflect the coverage they would have without Medicare until the hold harmless period has ended. For example, an individual who should be Medicare primary would show Ind 1 Med (letter A on bill), but if they are being held harmless, they will show Empl Only (1 on the bill). A Family with one person on Medicare will show Fam 1 Med (letter B on the bill), but if being held harmless it would show Family in NYBEAS (4 on bill). Please see the chart attached to help you understand the coverage description.
Note: Once the hold harmless period has ended the coverage description will change back to the code that reflects the Medicare prime coverage.
For enrollees and dependents who are enrolled in Medicare Part B only and are being held harmless for Medicare Part A claims, the Medicare primacy indicator will be updated in NYBEAS, the individual will be enrolled in the Empire Plan Medicare Rx, and you will be billed the MediPrime rate. This is because individuals who are held harmless for Medicare Part A are usually held harmless for Part A claims indefinitely.
For more information on the hold harmless process, please refer to Policy Memo 70r4.