Pregnancy soon to be a qualifying event
On June 17, the New York state Assembly and Senate unanimously passed S. 5972. The legislation makes pregnancy a qualifying event through the state-run exchange, New York State of Health. Governor Cuomo is expected to sign the bill, and New York will become the first state in the nation where pregnancy would allow a woman to enroll in a plan through the exchange. If signed into law, the regulation would go into effect in January 2016, and would allow a pregnant woman to enroll with an effective date of the first of the month in which her pregnancy is confirmed.
Under federal ACA rules, the baby’s birth triggers a qualifying event, but pregnancy does not. Advocates have pushed for the inclusion of pregnancy in the list of qualifying events at a federal level, but although HHS considered that possibility in their most recent update on qualifying events, they noted in February that they had opted not to include pregnancy as a qualifying event. That could still change in the future however, and the success of the legislation in New York will certainly put pressure on other state-run exchanges to follow suit.
California has similar pending legislation, although it’s more specific in terms of what would be allowed, and it wouldn’t go into effect until 2017. In California, the legislation clarifies that only women without minimum essential coverage would be allowed to enroll upon becoming pregnant – so the qualifying event triggered by pregnancy would be more limited than a regular qualifying event that allows people to switch from one plan to another. New York’s legislation does not have that sort of qualifying language, so it’s possible that pregnancy women in New York will have the option not only to enroll for the first time, but also to switch to another plan at the commencement of pregnancy.
New York is tied with Hawaii for having the highest rate of unintended pregnancies in the country (61 percent). Advocates have cheered the new legislation in New York, noting that pre-natal care increases the odds of a healthy, full-term pregnancy, and that unintended pregnancies necessitate the option to enroll in health coverage when a pregnancy is confirmed. But there are also concerns that this “loophole” in the enrollment system could result in adverse selection and higher premiums.
Carriers in New York’s individual insurance market have filed proposed rates for 2016 that amount to a weighted average rate increase of 13.5 percent. Two carriers – Independent Health Benefits and Metro Plus – have requested rate decreases for 2016. The other 16 carriers in the state’s individual market have requested higher rates for 2016.
But the state is closely scrutinizing those requests, and it should be noted that while rates only increased an average of 5.7 percent for 2015, carriers had initially requested average hikes of 12.5 percent. The New York Health Plan Association has stated that the final rate increases for 2015 were lower than the increase in claims costs, so it’s unclear whether the state will be able to reduce the proposed 2016 rates as sharply as they did last year.
The majority of New York State of Health’s enrollees are receiving premium subsidies, and those subsidies will mute the impact of any rate increases as long as consumers take the time to shop around during open enrollment. Open enrollment begins on November 1, and continues until January 31, 2016.
Basic Health Program coming in 2016
On April 17, New York State of Health announced that they will introduce a Basic Health Program (BHP) in the fall, available during the general open enrollment that begins on November 1. BHPs are an option available to all states under the ACA, but thus far, only New York and Minnesota have received federal approval for their BHPs.
In New York, the BHP will be available from a variety of private carriers, will have no deductible, and will have no premium for enrollees with incomes up to 150 percent of the federal poverty level. Enrollees with incomes at 200 percent of the federal poverty level will pay just $20 per month in premiums. Currently, enrollees with incomes between 138 percent and 200 percent of poverty are eligible for premium subsidies and cost-sharing subsidies, but switching to a BHP during the upcoming open enrollment may result in lower premiums and lower cost-sharing.
Single-payer in NY?
Although the BHP puts NY ahead of almost all other states in implementing the ACA and healthcare reform, advocates for single-payer healthcare are hard at work in the state. New York lawmaker Richard Gottfried (D-Manhattan) has been working on a plan for single-payer healthcare in the state, co-sponsoring – with Senator Bill Perkins – legislation that would create a universal coverage program known as “New York Health” and hosting a series of public hearings about the proposed plan.
Gottfried and Perkins introduced their bill nearly two years ago, in March 2013 (although Gottfried has been introducing similar bills since the 90s), and 83 other lawmakers signed on to co-sponsor it. Gottfried initially said the switch to single-payer would save $20 billion a year, but a new study in Mach 2015 found that the annual savings under a single payer plan would actually reach $45 billion, and would result in savings for 98 percent of NY residents.
In late May, the New York state Assembly voted 89-47 in favor of Gottfried’s New York Health Act, but the Republican-controlled Senate is not expected to pass the measure. So while the successful vote is certainly a victory for universal health care, it’s mostly a symbolic victory at this point.
Vermont was on a path to single-payer health care, but pulled the plug in late 2014 amid cost and taxation concerns.
Individual market enrollment in NY up 89%
In April, the Kaiser Family Foundation released a report on overall individual market growth from 2013 to 2014, based on enrollment data at the end of each year. The study looked at the entire individual market, including exchange plans, off-exchange plans, and grandmothered/grandfathered plans, and did not differentiate in terms of what percentage of the market growth could be attributed to exchange enrollment.
In New York, the individual market grew by 89 percent in 2014 – the fourth-highest percentage growth increase in the country. And KFF notes that three carriers in NY – Affinity, MetroPlus, and Fidelis Care – did not submit data for the survey, so it’s likely that the individual market growth is actually higher than 89 percent. Nationwide, individual market growth was 46 percent.
2015 enrollment progress
By the end of open enrollment on February 15, NY State of Health announced that their total enrollment, including private plans and Medicaid/CHIP, had exceeded 2.1 million people, and that 88 percent of them had been uninsured prior to obtaining coverage through the exchange.
564,315 of those enrollees have private plans (although the private plan enrollment total includes 156,827 Child Health Plus enrollees; the remaining 407,488 enrollees have QHPs). And total Medicaid enrollment through the exchange stood at 1,545,319 people as of February 15.
The majority of the current enrollees obtained coverage through the exchange in 2014 and renewed it for this year. But 552,993 enrollees are new to the exchange for 2015. Of those, about a third are enrolled in private plans (including Child Health Plus), and the rest are enrolled in New York’s expanded Medicaid program.
By February 21, HHS reported that NY State of Health’s private plan enrollment (not counting CHP) stood at 408,841, and that 35 percent of those enrollees are new to the exchange for 2015.
tax season special enrollment period
Open enrollment was scheduled to end on February 15, in New York and across the country. But on February 13, NY State of Health announced that anyone who has “taken steps to apply” on or before February 15 would have until February 28 to complete the enrollment.
In addition, on February 20, NY State of Health announced a special enrollment period (March 1 to April 30), for people who didn’t previously know about the ACA’s individual mandate penalty, and only found out about it when they filed their taxes and were subject to a penalty for 2014. By taking advantage of this special enrollment period, people who were subject to the penalty for 2014 were able to partially avoid the penalty for 2015 (the penalty is prorated for the number of months you’re uninsured, if your gap in coverage lasts more than two months).
Now that open enrollment and the tax season special enrollment have ended, you’ll only be able to get new coverage or switch plans for 2015 (including outside the exchange) if you have a qualifying event. The next open enrollment period begins on November 1, for coverage effective January 1, 2016.
The second round of open enrollment began on November 15, and navigators and brokers were impressed with the improvements that the exchange made since the first open enrollment, with one navigator organization pointing out that for most of the people they’re helping, the enrollment process takes half the time it did during the 2014 open enrollment period.
In November, soon after open enrollment began, NY State of Health executive director, Donna Frescatore, was predicting 350,000 new private plan enrollments for the exchange by February 15 (they had 132,549 as of February 4), in addition to retaining their 370,000 2014 enrollees.
That would put their target at 720,000 total private plan enrollees by the end of open enrollment, and clearly they fell short of that goal. But ACAsignups’ Charles Gaba – who is usually very accurate in his predictions – had a lower projection for NY State of Health (573,000 by February 15), and the exchange came very close to reaching that mark. Once the totals are in for the tax season special enrollment period, it’s likely that they could exceed 573,000 private plan enrollees.
Officials believe that after three years, there will be 615,000 people enrolled in private plans through the exchange (although far more than that will likely enroll over the course of three years, the individual health insurance market has always been volatile, and attrition is to be expected as time goes by).
The exchange allowed automatic renewal for people who, during their 2014 enrollment, granted the exchange permission to access their tax returns in subsequent years to verify subsidy eligibility. But even if your plan was automatically renewed, it was still worth your while to compare the 2015 plans during open enrollment to see if a different plan offered a better value this year. NY State of Health created a video that explained what you needed to do if you already purchased a plan in 2014.
NY State of Health has added a feature to their website that allows users to browse plans, including estimated premium subsidies, by entering some very basic information about their age, location, and income. During the first open enrollment period this wasn’t available – people had to enter identifying data in order to see prices that included subsidies. The improvement – similar to one that Healthcare.gov made for people in states with federally facilitated marketplaces – makes the website more user friendly.
How successful is NY State of Health?
NY State of Health was working well early in October 2013, at a time when HealthCare.gov and many of the state-run exchanges were still struggling. And just before the second open enrollment began, the New York State Health Association released the results of a survey that found 92 percent of the 2014 NY State of Health enrollees are satisfied with their coverage, and three quarters of the exchange’s enrollees would recommend NY State of Health to other people.
2015 rates and changing benchmark plans
Has the law delivered affordable health insurance to the state? Rates for 2015 were approved in New York in early September 2014. In the individual market (both on and off-exchange), the average approved rate increase is just 5.7 percent – a significant decrease from the 12.5 percent that carriers had originally filed with the state. This chart shows each carrier by market share, and hovering over a carrier’s segment of the chart allows you to see their approved rate increase for 2015.
But as of November 11, PricewaterhouseCooper’s weighted average rate increase across 21 carriers in New York was just half a percent for 2015, ranging from a decrease of 15.3 percent to an increase of 13 percent. Any way you look at it, rates in New York look pretty good.
Within the exchange, the second-lowest cost Silver plan (the benchmark plan) in New York City averaged $365/month (pre-subsidy) for a 40 year-old enrollee in 2014. That’s gone up to $372/month for 2015 – an average increase of just 1.8 percent. But that’s assuming that the applicant again selects the second-lowest-cost Silver plan in 2015, which often means switching plans.
The Upshot from the NY Times released a map that shows each state broken into rating areas and the average price changes that enrollees in the 2014 benchmark plan can expect if they stay with their plan from 2014, versus switching to the new benchmark plan for 2015. In some areas of New York, it makes a dramatic difference in premium. Regardless of where you live, it’s in your best interest to take a few minutes to shop around again before settling on a plan for 2015.
Carriers offering 2015 policies
NY State of Health announced on September 22 that sixteen carriers would be offering coverage in the individual market for 2015, and nine carriers would offer small business coverage through the SHOP exchange (carriers’ phone numbers and provider network links are available here).
American Progressive Life and Health Insurance Company of NY will no longer be selling policies after gaining a very small market share in 2014. But WellCare has joined the exchange for 2015.
NY State of Health is also offering stand-alone dental plans from ten different carriers for 2015. Across all three types of coverage – individual, small group, and dental – there are a total of four new insurers on the NY exchange for 2015.
Sixteen insurers – double the national average – are participating in the state’s individual marketplace for 2015:
- Affinity Health Plan, Inc.
- Capital District Physicians Health Plan, Inc.
- Health Insurance Plan of Greater New York (EmblemHealth)
- Empire BlueCross and Empire Blue Cross Blue Shield
- Excellus (Excellus Blue Cross Blue Shield in Central NY and Univera in Western NY)
- Fidelis Care
- Freelancers Co-Op (Health Republic Insurance)
- Healthfirst New York
- HealthNow New York, Inc. (Blue Shield of NENY; Blue Cross Blue Shield of Western NY)
- Independent Health
- MetroPlus Health Plan (Market Plus)
- MVP Health Plan, Inc.
- North Shore LIJ
- Oscar Insurance Corporation
- United Healthcare of New York, Inc. (United, Oxford)
Regulations, funding, and legislation
In late-April 2014, officials decided that carriers would not be required to cover out-of-network care in order to sell plans for 2015. This was a contentious issue during the first open enrollment, as none of the 16 carriers offering plans in the NY exchange cover out-of-network care unless it’s an emergency. Consumer advocates had pushed to require plans to cover out-of-network care, citing the narrow networks as a barrier to care for some residents. But insurers pushed back, noting that plans would be more expensive if they covered services provided outside of the established networks – ultimately, the exchange agreed.
State-run exchanges across the country are scrambling to figure out how to obtain funding going forward, as they are all expected to be financially self-sustaining by 2015. New York State of Health is planning to rely solely on state funds to pay for the exchange next year (as opposed to user fees).
But in early February 2015, Governor Andrew Cuomo unveiled his 2015-2016 executive budget, which includes a new tax on health insurance premiums (roughly $25 per person) for private plans sold on and off the exchange. The tax is projected to raise about $69 million, but health insurance carriers are opposed to the tax, as they say it will make health insurance less affordable for NY residents.
New York Governor Andrew Cuomo included the ACA’s Basic Health Program in his budget proposal released in late January 2014. As noted above, the BHP will be available for people with incomes between 138 percent and 200 percent of poverty by 2016. Although provisions for the BHP were included in the ACA, only a handful of states have thus far expressed interested in pursuing the BHP as a way to provide health insurance for low income residents who don’t qualify for Medicaid. That NY is among them is no surprise, given how dedicated the state has been to implementing and supporting the ACA.
Given the success of the exchange, officials in New York declined President Obama’s offer to allow health insurance plans scheduled for year-end termination to be extended into 2014. Roughly 100,000 NY residents received cancellation notices, but that figure is dwarfed by the number of people who enrolled in exchange plans with January 1 effective dates, so it’s likely that most of the cancelled plans were replaced with new ACA-compliant plans.
New York State of Health has been one of the most successful exchanges in the country. As of April 15, 2014, 370,604 New Yorkers had enrolled in private health plans through NY State of Health, and another 590,158 had enrolled in Medicaid or CHIP, bringing total enrollment to 960,762.
This was a significant increase from the 812,000 people who had enrolled as of early in the day on March 31. Of the people who selected private plans, 74 percent received subsidies – lower than the national average of 85 percent. New York’s enrollment included a slightly higher percentage of “young invincibles” (people between the ages of 18 and 34), at 31 percent , than the national average of 28 percent.
Enrollment data – current as of September – is available based on zip codes (impressive considering the state has 2,200 zip codes!) in an interactive map created in November by Capital New York. And it’s broken down into QHP, Medicaid and CHIP totals to give a very accurate picture of where the exchange has had the most impact.
Among the 2014 enrollees, more than 80 percent were uninsured prior to enrolling in coverage, so NY is certainly making a huge dent in its uninsured population.
NY State of Health History
New York launched its consumer-facing website for its health insurance marketplace, NY State of Mind, on Aug. 20, 2013. The website included FAQs, an interactive map showing which health plans are available by county, and a calculator to help consumers learn if they are eligible for tax credits and how much they will pay for health insurance.
Gov. Cuomo established New York’s marketplace, or health insurance exchange, through an executive order. Cuomo issued the order in April 2012 after New York’s legislature failed to approve an exchange law in both the 2011 and 2012 sessions.
Cuomo cited numerous reasons in his executive order for starting an exchange. According to the governor’s office, state and local governments pay more than $600 million every year to cover the health care costs of uninsured individuals. Uninsured individuals, the order read, “frequently forego preventive care and other needed treatment, putting them at risk of being sicker throughout their lives and dying sooner than those who have health insurance, which diverts funds from other public uses …”
New York enacted ACA-style reforms in the individual market two decades ago; policies there have been guaranteed issue and community rated ever since. This meant that premiums in New York were far higher than in other states where medical underwriting was utilized. There was no individual mandate, and few insurers participated in the pre-ACA individual market in New York.
The ACA’s individual mandate has increased the number of carriers offering policies in New York, and premiums in 2014 were more than 50% lower than they were in 2013, and that will continue to be the case in 2015. Combined with the ACA’s premium subsidies, these changes make individual health insurance far more affordable in New York than it used to be.
Carriers are also allowed to offer plans outside the exchange in NY, but they are required to offer the same policies in the exchange that they offer outside the exchange, which means there aren’t many reasons for consumers to shop off-exchange in NY.
About 2.7 million people in New York — about 16 percent of the population — did not have health insurance in 2013, according to the Urban Institute. About 1.1 million are expected to buy insurance through the new marketplace.
Contact the New York exchange
NY State of Health
More New York health insurance exchange links
State Exchange Profile: New York
The Henry J. Kaiser Family Foundation overview of New York’s progress toward creating a state health insurance exchange.
Health Care For All New York (HCFANY)