The LIA Health Alliance is a Health Purchasing Cooperative (HPC) that is designed to increase insurer competition and significantly expand choices for small businesses and their employees. It gives small businesses the same marketplace advantages enjoyed by large corporations. It is the first Alliance authorized by New York State.

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A Health Maintenance Organization (HMO) is a benefit plan that has one benefit level: in-network. It allows enrolled members, who live in a defined service area, to use participating HMO providers in order to receive benefits. HMO members must have all care authorized by their Primary Care Physician (PCP). There are minimal copayments, but no deductibles and virtually no claim forms. There aren't any out-of-network benefits.

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A Point-of-Service (POS) is a benefit plan that has two benefit levels: in-network and out-of-network. In-network benefits provide the maximum benefit to members and provide the same cost and quality controls of the HMO product with minimal co-payments. To maximize in-network benefits, members are required to select a PCP from the insurer's directory of participating providers; the member's PCP will coordinate all of the members' health care needs. Members can choose, at the time services are needed, to seek care from an in-network provider and receive the highest benefit level possible or go out-of-network and receive benefits that are subject to deductibles and coinsurance.

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An Exclusive Provider Organization (EPO) is a benefit plan that has one benefit level: in-network. In-network benefits provide maximum benefit to members with minimal co-payments. Referrals are not required to access in-network benefits. Members must select in-network providers to seek care for needed services. There aren't any out-of-network benefits.

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A Preferred Provider Organization (PPO) is a benefit plan that has two benefit levels: in-network and out-of-network. In-network benefits provide the maximum benefit to members with minimal copayments. Referrals are not required to access in-network benefits. To maximize in-network benefits, members must select in-network providers to seek care for needed services. Members can choose, at the time services are needed, to seek care from an out-of-network provider and receive benefits that are subject to deductibles and coinsurance.

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The Alliance standardizes most of the HMO, EPO, POS and PPO benefit plans to facilitate competition...though there are minor benefit variations. Each insurer prices (rates) those same benefit plans. This gives you the ability to make meaningful rate comparisons in a quick and easy fashion. The Alliance also allows each insurer to offer a specialty benefit plan that is unique to that insurer.

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The monthly rates for each insurer is shown in the Rate Comparison Sheet. The sheet lists the rates by insurer, benefit plan and tier level. This sheet will be given to you by your employer. Your employer will tell you: what the company tier level will be and what the company contribution will be.

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Select the benefit plan and the insurer that best meet your personal needs and complete the Healthcare Enrollment/Change Form. Please sign the enrollment form and return the completed form to your employer. Your employer also will sign the enrollment form and forward it to the Alliance Enrollment Processing Center.

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Yes. The LIA Health Alliance offers dependent coverage to all eligible employees. Dependents must be listed on your enrollment form for dependent coverage to go into effect. An eligible dependent is defined as your spouse and any unmarried child (adopted, under legal guardianship, a stepchild, or a natural child) of the eligible employee. An un-married dependent child is covered up to age 19.
Children incapable of self-support due to physical or mental disability will continue to be covered until termination of the disability.
An unmarried child registered as a full-time student can be covered up to age 25 on most of the benefit plans offered.

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You can select a primary care physician in any of the New York Counties listed in the provider directories of the participating insurers.

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If you experience a significant life status change during the year, you can change your dependent coverage (eg., Employee, Employee & Spouse, Employee & Child(ren) or Family) but not the benefit plan or the insurer that you have selected. The company tier level selected by your employer cannot be changed.
Significant life status changes include: marriage; divorce; death; birth; adoption/legal guardianship; or loss of eligibility for health coverage due to termination of employment (except for reasons of gross misconduct) or reduction in work hours below 20 hours per week.
Any significant life changes must be reported on a Healthcare Enrollment/Change Form and sent to the Alliance Enrollment Processing Center.
The Enrollment Form must be received within 30 days of the qualifying event. Please contact the Alliance Enrollment Processing Center at 1-800-LIA-5513 for additional information.

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All four participating insurers allow female members to visit both a PCP and an OB/GYN without referrals.

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All enrollment materials must be received at the Alliance Enrollment Processing Center on or before the last business day of the current month to be eligible for coverage on the first day of the next month.
Any enrollment information received after the last business day of the current month will be processed for coverage the first day of the month that follows that next month.

Check with your employer to verify your effective coverage date. Your employer has established a new hire waiting period for your company. For new employees, coverage will begin the first day of the month following that waiting period. Your enrollment form must be received prior to that date or your coverage won't begin until the first day of the next month.

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A pre-existing limitation will not apply, if you have been continuously insured by creditable coverage for 12 months without a lapse of coverage exceeding 63 days.

A pre-existing condition is a sickness or injury (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six month period prior to the enrollment date. Health insurers can exclude coverage for up to twelve months for pre-existing conditions.

The twelve month exclusion period will be reduced provided that not more than 63 days have elapsed between the date the person's preceding health care coverage terminated and the enrollment date of the new coverage.

Coverage will be credited:
(a) for the length of time that the person was previously covered under previous creditable health care coverage; or
(b) by any affiliation (waiting) period prior to previous health maintenance organization coverage.

Creditable coverage includes: a group health plan; health insurance coverage; Part A or B of Medicare; Medicaid; military sponsored health plan; Federal Employees Health Benefit Plan (FEHBP), and a public health plan.
The Pre-existing condition exclusion does not apply to:
(a) genetic information unless a condition related to that information is diagnosed;
(b) pregnancy;
(c) newborns who became covered within 30 days of the date of birth; or
(d) child, who is adopted or placed for adoption before attaining eighteen years of age, became covered within 30 days of the date of the adoption or placement for adoption.

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If there is a loss of coverage due to a reduction in work hours, termination of employment (except gross misconduct), disability, death, legal separation or divorce, Medicare entitlement or change in dependent eligibility, an employee may be eligible to continue coverage through COBRA (Consolidated Omnibus Budget Reconciliation act). With COBRA the employee is responsible for payment at the group premium rate plus 2% for administration expenses.

To be eligible, the employee must be enrolled under their employer's group health plan at the time of the qualifying event.

Continued coverage is available for a maximum of 36 months. The LIA Health Alliance does administer COBRA benefits. The process begins with your employer. Your employer will provide you with notification of your rights and responsibilities under COBRA in the event you have a qualifying event. Direct pay conversion may be available from each insurer.

The employer is responsible for notifying COBRA participants that their coverage is terminated, if and when the company's health insurance plan is terminated.

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Questions about the Alliance or the enrollment process should be discussed with your employer. If you have questions about PCP selections, provider directories, ID cards, benefit plans or claims, please contact the selected insurer at the toll-free numbers provided on your ID card, in the Insurer Descriptions section or in the Insurer Information section in the Employee Selection Guide.

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Yes. However, if you cancel coverage, you will only be able to re-enroll during the next renewal time period for your company...unless you experience a significant life status change.

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Electronic debiting brings electronic funds transfer technology to the health insurance bill payment process. Electronic debiting is the simplest and most worry-free way to pay your monthly health insurance bills. On or about the 15th day of each month, you will receive an itemized bill from the LIA Enterprise Enrollment Processing Center. The bill details the premium dollars that are due the first day of the following month. On the last business day of the month, a debit request will be sent to the bank you have designated and the payment due will be electronically transferred to the Enterprise. You won't have to worry about making late payments.

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They can select a primary care physician in any of the New York Counties listed in the provider directories of the participating insurers.

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An employer contribution program allows you to fix your company's insurance costs. You can select a fixed dollar amount, a percentage of premium or whatever financial formula is best for your company.

When you decide what the employer contribution will be, you should inform your employees of that amount. This financial information is an important decision factor in the employee selection process.

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It is important that you inform each eligible employee that they can make insurer selections and benefit plan selections that meet their personal needs. Distribute the Employee Selection Guide, the rate comparison sheet and a Healthcare Enrollment/Change Form to each one of your employees. You should also tell each employee to list the dependents that they want covered on their enrollment form.

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