XII. Interplan Telecommunications System (ITS)


Question 1: How do the HCRA surcharge obligations and election provisions of HCRA apply to a self-funded plan that uses an out-of-state BCBS plan as their TPA?

Question 2: Does a negotiated rate agreement between a designated provider and a NY- based BCBS plan apply to out-of-state BCBS plans?



Question 1: How do the HCRA surcharge obligations and election provisions of HCRA apply to a self-funded plan that uses an out-of-state BCBS plan as their TPA?

Answer 1: The HCRA filing requirements for many out-of-state BCBS plans are affected by a special agreement between the DOH and Empire BCBS (Empire). In short summary, Empire acts as a conduit for the payment of claims in NYS through the Interplan Telecommunications System (ITS) for out-of-state BCBS plans. As such, Empire is the payor for purposes of HCRA. Therefore, when services are provided by designated providers to beneficiaries of out-of-state BCBS plans, and Empire is the agreed conduit for HCRA, Empire is considered the payor of the claim, and as the payor, is obligated to remit the PGP reports, surcharge payments and covered lives, if applicable, to the Office of Pool Administration.

Consequently, for claims that fall within the ITS, and have Empire act as their conduit to the PGP, Empire's election into the PGP protects these out-of-state plans from paying the higher surcharge. Empire files the PGP reports and submits the surcharge under their election and bills the out-of-state BCBS plans. If Empire is not the agreed conduit for ITS claims and PGP reporting, then the out of state BCBS plan (as an insurer) or the plan itself (as the payor assuming risk for claims) must be an elector in order to receive the advantages of the election. As an elector, they would be obligated to file the obligated PGP reports, and submit surcharge and covered lives assessments, if applicable.

For claims that fall outside of ITS, the payor of the claim (either the out-of-state BCBS plan as an insurer or the self-funded client of the out-of-state BCBS plan) must have their own election on file to be able to pay the lower surcharge rate. Under this scenario, the payor is required to fulfill their HCRA obligations consistent with their election regardless of whether they incur any non-ITS surchargeable claims or not. Failure to meet these obligations could jeopardize their election status.

Similar to the HCRA surcharge, if the self-funded clients of an out-of-state BCBS plan have a covered lives obligation, Empire will remit the required reports and payments under its own election and bill the out-of-state BCBS plan.

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Question 2: Does a negotiated rate agreement between a designated provider and a NY- based BCBS plan apply to out-of-state BCBS plans?

Answer 2: A negotiated rate agreement between a designated provider and a NY based BCBS plan applies to out-of-state BCBS plans provided: 1) the out-of-state plans are participating in the NY based BCBS plan's ITS (most likely Empire); and 2) the contractual agreement between the designated provider and the NY- based BCBS plan contains provisions which specifically provide that NY negotiated rates apply to such out-of-state BCBS plans.

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