Find a plan.

New York health insurance marketplace guide 2023

Open enrollment for 2023 coverage continues throughout the federal COVID public health emergency in New York (scheduled to end May 11, 2023)

New York health exchange overview

New York State of Health is one of the most robust health insurance exchanges in the country, with a dozen carriers offering individual market plans.

Insurers implemented an overall average rate increase of 9.7% for 2023, which was (as usual) quite a bit smaller than the average increase proposed by the insurers.

The official open enrollment period for 2023 coverage ran from November 16, 2022 through January 31, 2023 (differing from the rest of the country on both the start and end dates), but as was the case throughout 2022, open enrollment in New York is continuing during the federal COVID public health emergency.

The public health emergency is slated to end on May 11, 2023. From that point until November 16, 2023 (when open enrollment begins for 2024 coverage in New York), New Yorkers will need to have a qualifying event in order to sign up for qualified health plans. As usual, enrollment in Medicaid, Child Health Plus, and the Essential Plan will continue year-round for people who are eligible for those programs.

221,895 people have enrolled in private individual market plans through the New York exchange during open enrollment for 2022 coverage (by January 15, 2023, enrollment in private plans for 2023 had reached 212,580 in New York). And far more people — more than 1.1 million were enrolled in coverage through New York’s Essential Plan by mid-January 2023. The Essential Plan is a Basic Health Program that eligible residents can enroll in via the New York exchange. (Minnesota is the only other state with a BHP, although Oregon is working to establish one, and West Virginia is considering legislation to create one.)

New York plans to seek federal permission to extend its Basic Health Program so that it covers people with income up to 250% of the poverty level, instead of the current 200% cap.

Frequently asked questions about New York's ACA marketplace

New York has fully embraced the Affordable Care Act, with a state-run exchange, called New York State of Health. It is one of the most robust exchanges in the country, with 12 insurers offering individual market plans for 2023. (Plan availability varies considerably from one county to another, and some insurers sell plans under more than one name).

There are also 12 insurers offering Essential Plan coverage for 2023 (this is New York’s Basic Health Program — details below; availability varies from one county to another), and seven insurers offering small business plans through NY State of Health’s SHOP exchange (plan availability varies from one county to another; some insurers market plans under more than one name).

The same twelve insurers that offered exchange plans in New York for 2022 are continuing to do so for 2023:

  • Capital District Physicians’ Health Plan (CDPHP)
  • Emblem (Health Insurance Plan of Greater New York)
  • Excellus Health Plan
  • Fidelis (New York Quality Health Care Corp.)
  • Healthfirst PHSP
  • Health Plus HP (formerly Empire)
  • Highmark Western and Northeastern New York (formerly HealthNow)
  • Independent Health Benefits Corporation
  • Metro Plus Health Plan
  • MVP Health Plan
  • Oscar
  • UnitedHealthcare of New York

New York has had a robust exchange from the start, with multiple insurers offering plans in most areas of the state. 

For the most part, insurer participation has been fairly stable in New York’s exchange. But there have been a few changes over the years:

  • WellCare exited the individual QHP market at the end of 2016 (but continued to offer the Essential Plan coverage). Their enrollee count in exchange QHPs was only about 1,000 members in 2016.
  • American Progressive Life and Health Insurance Company of NY didn’t offer policies for 2015 after gaining a very small market share in 2014.
  • WellCare joined the exchange in 2015 but only offered plans for two years. They stopped offering exchange plans at the end of 2016.
  • Health Republic closed in late 2015, so their policies were not available for 2016 or later years (more details below).
  • For 2016, Health Republic was no longer available.
  • Affinity Health Plan, which had 6,353 enrollees in 2017, exited the individual health insurance market in New York at the end of 2017. They did not offer 2018 coverage on or off-exchange.
  • CareConnect, operated by Northwell Health, New York’s largest hospital system, announced in August 2017 that they would shut down Care Connect Insurance Company over the coming year. The insurer stopped offering coverage at the end of 2017. Their 31,266 members in the individual market had to select new coverage for 2018. CareConnect also had 79,337 members in the small group market; those plans were allowed to remain in force until their renewal date in 2018.

In September 2017, Centene announced plans to acquire Fidelis Care’s assets. (Technically the transaction was “an asset purchase, rather than an outright acquisition” in order to comply with New York regulations regarding the purchase of nonprofit organizations.) Centene did not previously participate in New York’s market, but the acquisition of Fidelis Care gave the company major foothold there, given Fidelis Care’s market share.

Centene agreed to pay $3.75 billion to purchase Fidelis Care’s assets, but the state believed that the majority of that money should go to the state, since Fidelis Care’s primary business is Medicaid managed care. A deal was reached in March 2018 that allows the state to receive $2 billion from the sale, with the money earmarked for a healthcare charitable trust to benefit New Yorkers and improve health care in the state. In April 2018, the New York Department of Health and the New York Department of Financial Services both granted approval for the acquisition, and the details were finalized by the end of 2018.

In New York, the open enrollment period has both a start and end date that differ from the schedule used in most other states. And New York has also been keeping its enrollment portal open throughout the COVID public health emergency, which is scheduled to continue through May 11, 2023.

Normally, open enrollment starts November 16 in New York, and continues through January 31 (as opposed to the November 1 – January 15 schedule that’s used in most of the rest of the country).

But enrollment was open throughout 2022 in New York, due to the ongoing COVID public health emergency. And that continues to be the case in early 2023. The federal COVID public health emergency is slated to end on May 11, 2023.

So from May 12 until November 16, 2023 (when open enrollment begins for 2024 coverage in New York), New Yorkers will need to have a qualifying event in order to sign up for private qualified health plans.

But enrollment in Medicaid, Child Health Plus, and the Essential Plan will continue to be available year-round for people who are eligible for those programs. 

The overall weighted average rate change for 2023 qualified health plans in New York amounted to an increase of 9.7%. This was larger than the national average for 2023, but it was only a little more than half of the rate increase that New York’s insurers had proposed for 2023. As has been the case in prior years, the NY Department of Financial Services approved significantly smaller rate increases than the insurers had proposed.

The following average rate changes were approved for the insurers that offer individual/family coverage through New York State of Health (rate changes are calculated before premium subsidies are applied; data regarding the number of enrollees for each insurer can be found here):

  • Capital District Physicians’ Health Plan (CDPHP): 16.5% increase
  • Emblem (Health Insurance Plan of Greater New York): 9% increase
  • Health Plus HP (formerly Empire): 0.5% increase
  • Excellus Health Plan: 10% increase
  • Fidelis (New York Quality Health Care Corp): 12.4% increase
  • Healthfirst PHSP: 8.3% increase
  • Highmark Western and Northeastern New York (formerly HealthNow): 12.8% increase
  • Independent Health Benefits Corporation: 6.1% increase
  • Metro Plus Health Plan: 8.1% increase
  • MVP Health Plan: 10.1% increase
  • Oscar: 6.5% increase
  • UnitedHealthcare of New York: 9.2% increase

It’s important to understand that net rate changes for people who receive premium subsidies can be quite different from the overall rate changes for that person’s plan, since it also depends on how the benchmark plan premium changes.

For perspective, here’s a look back at rate changes for NY State of Health plans since 2014:

2014: ACA-compliant plans debuted in 2014. And although premiums in most states increased as insurers switched from medically underwritten to guaranteed issue coverage, that was not the case in New York. Premiums were already high in New York, as the state had required guaranteed issue coverage for more than two decades. So premiums in New York in 2014 were lower than they had been the year before (thanks to the ACA’s individual mandate, which New York didn’t have in previous years).

2015: Average increase of 5.7%. 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 was just 5.7% – a significant decrease from the 12.5% that carriers had originally filed with the state.

2016: Average increase of 7.1%. In the individual market, carriers had requested an average rate increase of 10.4 percent for 2016, but regulators knocked that down to 7.1 percent — and some insurers reduced their average prices for 2016. Health Republic initially had the highest approved rate increase (14 percent), but their plans terminated at the end of November 2015 (details below). Since all of Health Republic’s individual enrollees had to switch to other carriers during open enrollment, the final weighted average rate increase ended up being less than the 7.1% that regulators had initially stated.

2017 Average increase of 16.6%. Nationwide, the average pre-subsidy premium increase was about 25% for 2017, while New York’s weighted average rate increase for the individual market was 16.6%. So although NY had a double-digit average increase, premiums in the state were more stable than they were in other states.

2018 Average increase of 13.9%. Insurers proposed an average increase of 17.7% for 2018 individual market plans, but NYDFS approved an average rate increase of 13.9%.

NY Upstate reported on May 15 that insurers in New York would be requesting “double-digit rate hikes because of continued increases in health care costs and uncertainty related to federal discussions surrounding repealing and replacing the Affordable Care Act.”

In their summary of rate filings for 2018, NYDFS included this:

to prepare for potential changes to the Affordable Care Act, DFS requested that insurers provide estimates as to how the impact of a potential repeal of the individual mandate and the loss of Cost Share Reduction (CSR) funding would affect rates. Of those that provided numerical estimates, on average, insurers estimated that a full repeal of the federal individual mandate would increase rates by an additional 32.6% and the loss of CSR funding would increase rates an additional 1.3%.

The elimination of CSR funding had less of an impact in New York than it would in most other states (for example, Pennsylvania regulators estimated that loss of CSR funding would increase premiums by more than 20 percent). That’s because of New York’s Essential Plan, which covers people with income up to 200% of the poverty level. CSR is available to people with income up to 250% of the poverty level, but its impact is much smaller when incomes are above 200% of the poverty level. In most states, people with income up to 200% of the poverty level are eligible for substantial CSR benefits, but that’s not the case in New York, since those residents are instead eligible for the Essential Plan.

2019: Average increase of 8.6%. The average approved rate increase for 2019 was 8.6%. But that was quite a bit lower than insurers had proposed. A recurring theme in each insurer’s filing was the fact that the impending elimination of the individual mandate penalty (after the end of 2018) was a major factor in the proposed rate increases. After reviewing the proposed rates, DFS noted that the average proposed rate increase was 24 percent, but it would only have been 12.1% if the federal government hadn’t repealed the individual mandate penalty.

It’s worth noting that in the 90s, New York implemented guaranteed-issue and community rating, but did not impose any sort of mandate. The predictable result of that was skyrocketing premiums and dwindling insurer participation in New York’s individual market. But New York’s pre-2014 market also didn’t have limited enrollment periods or premium subsidies for middle-class enrollees, and those factors have helped to stabilize the individual market and prevent the sort of death spiral that it experienced in the pre-ACA years. But the loss of the individual mandate penalty was by far the single biggest factor in the higher rates that New York insurers were proposing for 2019.

Maria Vullo, DFS Superintendent, previously explained in an op-ed that the actions the Trump administration and GOP lawmakers have taken (elimination of the individual mandate in 2019, the elimination of cost-sharing reduction funding, and the shorter open enrollment period) were resulting in higher health insurance premiums in the individual market. But Vullo clarified that DFS would “be particularly focused on making sure that insurers do not use the chaos and fear-mongering from Washington over the last 18 months as a cover for excessive increases.”

And sure enough, when the approved rate increases for 2019 were announced in August 2018, they were dramatically smaller than insurers had proposed.

2020: Average increase of 6.8%. Across all plans in the individual market, the average proposed increase was 9.2 percent. But regulators spent several weeks reviewing the rates, and as in past years, the overall average approved rate increase of 6.8 percent was smaller than the insurers proposed.

Outside the exchange, HealthFirst Insurance Company offers off-exchange-only plans. An average rate increase of 9.8 percent was approved for their plans for 2020. HealthFirst Ins. Co. had just 149 enrollees in 2019.

Crystal Run Health Plans, which had only been offering coverage outside the exchange in New York, wound down its health plans at the end of 2019 and did offer coverage for 2020. UnitedHealthcare Insurance Company of New York, which only offered plans outside the exchange had had just 52 enrollees in 2019, had proposed an average rate increase of  29 percent for 2020, but their filing was not included among the approved rates for 2020.

New York continues to instruct insurers to add the cost of cost-sharing reductions (CSR) to the premiums for all individual market silver plans, since the federal government is no longer funding CSR.

2021: Average increase of 1.8%. In June 2020, New York’s Department of Financial Services posted insurers’ rate filings for 2021 coverage, which amounted to a weighted average rate increase of 11.7%.

But in August, once the rate review process was completed, NYDFS announced that the overall approved average rate increase for the individual market would be just 1.8% — the smallest percentage increase in the last decade. And in the small group market, the average approved rate increase was 4.2%, as opposed to the 11.4% average increase the insurers had proposed.

2022: Average increase of 3.7%. The overall weighted average rate increase for 2022 amounted to 3.7%, which was the second-smallest percentage increase since ACA-compliant plans became available in 2014.

New York’s individual/family market insurers initially proposed a weighted average rate increase of 11.2% for 2022, but as had been the case over the last several years, the New York Department of Financial Services approved rate increases that were quite a bit smaller than the insurers proposed.

During the open enrollment period for 2022 coverage, 221,895 people enrolled in private qualified health plans (QHPs) through NY State of Health. By mid-January 2023, enrollment in QHPs through NY State of Health had reached 212,580. Open enrollment was still ongoing at that point, and continues through May 11 in New York (the end of the federal COVID public health emergency). 

But the majority of the exchange’s enrollees have coverage through Medicaid, the Essential Plan (more than 1.1 million enrollees by early 2023), or Child Health Plus, with total enrollment across all programs standing at more than 6.5 million people by mid-2022. 

For perspective, here’s a look at QHP enrollment in New York State of Health since 2014:

  • 2014370,451 people enrolled in QHPs
  • 2015408,841 people enrolled in QHPs
  • 2016271,964 people enrolled in QHPs [enrollment dropped because New York’s Essential Plan (Basic Health Program) debuted for 2016, and people who had previously been receiving premium subsidies for QHPs became eligible for the Essential Plan instead. By the end of the open enrollment period for 2016, there were 379,559 people enrolled in the Essential Plan.]
  • 2017242,880 people enrolled (plus 665,324 people enrolled in The Essential Plan)
  • 2018253,102 people enrolled in QHPs (plus 738,851 people enrolled in The Essential Plan)
  • 2019271,873 people enrolled in QHPs (plus 790,152 people enrolled in The Essential Plan)
  • 2020272,948 people enrolled in QHPs (plus 796,998 people enrolled in The Essential Plan)
  • 2021215,889 people enrolled in QHPs (plus 914,000 people enrolled in The Essential Plan by late summer 2021) Note that 215,889 was the official CMS enrollment total as of the initially scheduled end of open enrollment. But open enrollment was extended due to COVID, and NY State of Health reported that the enrollment total had grown to 220,000 by the end of May 2021.
  • 2022: 221,895 people had enrolled in QHPs during the regularly schedule enrollment window. But New York’s open enrollment period for 2022 coverage continued throughout 2022, due to the COVID public health emergency. As of mid-2022, QHP enrollment stood at 225,726 people. 

In New York, the individual market grew by 89% in 2014 – the fourth-highest percentage growth increase in the country. Nationwide, individual market growth was 46%. The extreme growth in NY’s individual market was largely due to the fact that coverage became much more affordable in the state — even for people who didn’t qualify for premium subsidies — which was not the case in most states; New York already had guaranteed-issue coverage pre-ACA, whereas most states transitioned from medical underwriting to guaranteed-issue as of 2014.

Would ACA subsidies lower your health insurance premiums?

Use our 2023 subsidy calculator to see if you’re eligible for ACA premium subsidies – and your potential savings if you qualify.

Obamacare subsidy calculator *




Add ages of other family members to be insured.


Include yourself, your spouse, and children claimed as dependents on your taxes.


Modified Adjusted Gross Income (MAGI)

For most taxpayers, your MAGI is close to AGI (Line 11 of your Form 1040 in 2021 and 2022).

Estimated annual subsidy

Provide information above to get an estimate.

* This tool provides ACA premium subsidy estimates based on your household income. does not collect or store any personal information from individuals using our subsidy calculator.

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 were available by county, and a calculator to help consumers learn if they are eligible for tax credits and how much they would pay for health insurance. NY State of Health was working well early in October 2013, at a time when and many of the state-run exchanges were still struggling. 

Former 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 were paying 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 some ACA-style reforms in the individual market in the early 1990s; policies there have been guaranteed issue and community rated ever since. But there was no individual mandate, premium subsidy, or restriction on when people could enroll, and few insurers participated in the pre-ACA individual market in New York. So premiums in New York were far higher than in other states where medical underwriting was utilized.

The new provisions in the ACA — including the individual mandate, premium subsidies, and limited enrollment windows — have increased the number of carriers offering policies in New York, and inflation-adjusted premiums continue to be lower than they were prior to 2014. So individual insurance is far more affordable in New York than it used to be, and consumers have many more options for coverage.

A culture of consumer protections and health care reform

Over the years, New York has implemented various regulations to enhance consumer protections, including

  • Allowing a special enrollment period triggered by pregnancy (Connecticut, New Jersey, Maine, Maryland, and Washington DC are the only other places that offer this),
  • Creating a Basic Health Program (the Essential Plan) that covers people with income up to 200% of the poverty level. In 2023, New York plans to seek federal permission to extend this so that it covers people up to 250% of the poverty level (with a $15/month premium for the newly eligible population; people up to 200% of the poverty level get Essential Plan coverage for free),
  • Requiring insurers to remain in the exchange in order to keep their Medicaid/Essential Plan/Child Health Plus contracts,
  • Requiring contraceptive, abortion, and essential health benefits coverage on state-regulated plans (and as of 2020, state-regulated large group plans must cover IVF),
  • Insurers that offer plans through New York State of Health must offer one standard plan design in each metal level in every county where the insurer offers plans. Here are the details for 2023 standardized plans Carriers are also allowed to offer up to three non-standard plan designs in each metal level.
  • Not allowing grandmothered/transitional plans or short-term plans,
  • Surprise balance billing protections (federal surprise balance billing protections took effect nationwide in 2022),
  • Extending the definition of “small group” to groups with up to 100 employees (small group plans are more heavily regulated under the ACA than large group plans)
  • Not allowing premiums in the small group and individual market to vary based on age or tobacco use.
  • Capping the cost of insulin at $100 for a 30-day supply, for people with state-regulated health insurance (ie, this does not include self-insured group plans). Legislation was considered in 2022 to reduce this cap to $30, but it did not advance. But the issue is under consideration again in 2023 (S.504 and A.4141), and the Senate passed its version within the first few weeks of 2023.

New York’s Assembly has passed several bills over the years that would create a single-payer system in the state, but none of the bills have survived in the Senate. The 2022 legislation was A.6058 and S.5474, although neither advanced out of committee (those same bill numbers were introduced in 2021 as well, but did not advance out of committee).

Pre-subsidy premiums still lower in 2021 than they were in 2013

Premiums in New York’s exchange in 2021 were still considerably lower (after adjusting for inflation, but before applying applicable premium tax credits) than they were prior to 2014, when the bulk of the ACA was implemented (New York regulators consistently indicate that the rates remain 55% lower, but it’s probably more like 40% lower by now, given that rates have been steadily increasing in the years since 2014, after dropping substantially that year). In most states, unsubsidized premiums are significantly higher now than they were prior to 2014, but that’s not the case in New York.

That’s because in 1992, New York began requiring individual-market insurers to accept all applicants, cover pre-existing conditions, and charge the same premiums regardless of an applicants age. But the state did not have a mandate requiring people to have health insurance, so premiums rose significantly.

The ACA included an individual mandate as well as premium subsidies to keep coverage affordable for middle-class enrollees, and the result has been much lower premiums in New York since 2014. The mandate penalty was eliminated after the end of 2018, but New York regulators prevented insurers from raising their premiums in 2019 to compensate for the loss of the individual mandate penalty. And the ACA’s premium subsidies have ensured that coverage remains affordable for most enrollees, keeping most people in the market even if they don’t currently need extensive medical care.

Two bills were introduced in New York’s 2019 legislative session (A.1443, with an effective date of January 2019, and A.5203, which was identical except for a January 2020 effective date) that would have provided a state tax credit to offset some of the cost of health insurance, but neither bill advanced during the 2019 session. (Similar legislation (A.1184) was considered in 2017 but didn’t advance.) Fortunately, the federal government enacted the American Rescue Plan in 2021, making federal health insurance subsidies larger and more widely available. And these provisions were extended through 2025 by the Inflation Reduction Act.

The Essential Plan debuted in 2016. Enrollment had grown to more than 1.1 million, and New York plans to expand eligibility to 250% of the poverty level

In April 2015, New York State of Health announced that they would introduce a Basic Health Program (BHP) in 2016 dubbed the “Essential Plan.” Enrollment in the Essential Plan began on November 1, 2015 for coverage effective January 1, 2016. BHPs are an option available to all states under the ACA, but only New York and Minnesota elected to establish BHPs (Oregon is also considered a BHP as of 2023, and so is West Virginia).

Under ACA rules, BHP coverage is available to people with income too high for Medicaid but no higher than 200% of the poverty level. For 2022 coverage, that’s $25,760 for a single individual (it will be $29,160 once 2023 federal poverty level rules are in use, by the spring of 2023).

In New York, the BHP is available from a variety of private carriers, has no deductible and no monthly premium (prior to June 2021, there was a $20/month premium if a person’s income was above 150% of the poverty level, but that is no longer the case).

In 2023, New York is planning to seek federal permission to extend its BHP to cover people with income up to 250% of the poverty level. This newly eligible population would pay $15/month for very robust coverage. 

Prior to 2016, enrollees with incomes between 139% and 200% of poverty were eligible for premium subsidies and cost-sharing subsidies, but switching to the BHP has resulted in lower premiums and lower cost-sharing for many of them. About 40% of NY State of Health’s private plan enrollees in 2015 had incomes below 200% of the poverty level. They became eligible instead for the Essential Plan in 2016, which is a more affordable option than the coverage they had in 2015.

By January 31, 2016 enrollment in the Essential Plan had reached nearly 380,000 people. Essential Plan enrollment continues year-round, and by early 2020, enrollment had grown to 796,998. The COVID pandemic pushed it even higher, with 893,000 people enrolled in the Essential Plan as of May 2021. And enrollment climbed significantly after the $20/month premium was eliminated for people with income above 150% of the poverty level. By early 2023, enrollment in the Essential Plan stood at more than 1.1 million people.

It’s important to note that disenrollments due to eligibility redeterminations have been paused for the Essential Plan throughout the COVID pandemic, just like disenrollments for Medicaid and Child Health Plus. So enrollment has trended upward even more than it would otherwise have done. Eligibility redeterminations and disenrollments for people enrolled in the Essential Plan will resume in the spring of 2023.

Thanks to the American Rescue Plan, New York received an additional $750 million in federal funding for the Essential Plan. 

CSR funding and its impact on the Essential Plan

BHPs receive federal funding equal to 95% of the amount that the federal government would otherwise have spent on premium subsidies and cost-sharing reductions (CSR) in the state, if the BHP hadn’t been available to consumers. In October 2017, the federal government eliminated funding for CSR, nationwide. Insurers still have to provide CSR benefits to eligible enrollees, but instead of getting federal funds to cover the cost, insurers have instead added the cost to premiums (generally just to silver plan premiums) in nearly every state.

In New York and Minnesota, however, insurers didn’t have to add as much to their premiums to cover the cost of CSR, because very few people receive CSR benefits in those states, and the CSR benefits that are provided are very small. That’s because nearly everyone who would have been eligible for CSR in those states is eligible for BHP coverage instead. You can see how this devolves into circular logic…

In December 2017, the federal government informed New York and Minnesota that their BHP funding would be reduced by the amount that of the funding that had been attributable to CSR. In January 2018, the states sued the federal government, alleging that HHS “withheld legally required funding” for the Essential Plan and MinnesotaCare. The states had argued that if they didn’t have BHPs, their insurers would have added much larger premium increases to silver plans, which would have in turn resulted in more BHP funding due to the larger premium subsidies on which the BHP funding calculation would have been based. New York was facing a $1 billion shortfall in their budget due to the reduction in BHP funding (for Minnesota, it was about a $120 million shortfall, as MinnesotaCare has far fewer enrollees than NY’s Essential Plan). David Anderson, a research associate at Duke University Margolis Center, explained more about the case here.

Fortunately for New York and Minnesota, the judge ruled in May 2018 that HHS had to pay up. The ruling called for $169 million to be paid to New York and Minnesota for the second quarter of 2018 (of that, $152 million goes to New York, and $17 million goes to Minnesota), and for HHS to work together with the states to sort out a payment formula going forward.

In August 2018, HHS published a new methodology for calculating BHP payments for New York and Minnesota. It involves adding a “premium adjustment factor” of 18.8%, based on the estimation that premiums in NY and MN would have been 18.8% higher to account for the loss of CSR funding if the states didn’t have BHPs. Under the new methodology, New York received another $422 million in funding for the Essential Plan for 2018.

But HHS then proposed another adjustment for 2019 and 2020 BHP funding, which was expected to result in MN and NY losing a combined total of $300 million in BHP funding over the course of the two years. The new methodology kept the 18.8% premium adjustment factor, but it also takes into account the fact that an increasing number of people (in states that don’t have BHPs) with income under 200% of the poverty level are selecting bronze plans instead of silver plans, due to the low-cost or free bronze plans that have resulted from silver loading (the final rule only accounts for this in the 2020 plan year, but not for 2019).

Premium tax credits can be used to offset the cost of any metal-level plan, but the tax credits are never larger than the cost of the plan the person is buying. So if a person qualifies for a $500 premium tax credit and then purchases a bronze plan that would only cost $470 without the tax credit, HHS only has to pay $470, instead of $500. The increasing number of people buying bronze plans — some of which are less expensive than the premium tax credit the person would otherwise receive — resulted in a proposed change to the BHP payment methodology that will ultimately reduce the amount that NY and MN receive for their BHPs.

That same funding methodology (with the 18.8% premium adjustment factor, plus the adjustment to account for more people enrolling in bronze plans) was maintained for 2020 and 2021. But as noted above, CMS has also given New York an additional $750 million in federal funding for the Essential Plan, as part of the American Rescue Plan Act.

Pregnancy is a qualifying life event in New York

In June 2015, the New York state Assembly and Senate unanimously passed S. 5972. And on December 22, 2015, Governor Cuomo signed the legislation into law. The legislation makes pregnancy a qualifying event through the state-run exchange, New York State of Health, and took effect in January 2016. The law allows a pregnant woman to enroll with an effective date of the first of the month in which her pregnancy is confirmed by a licensed healthcare provider.

New York was the first state in the nation where the commencement of pregnancy allows a woman to enroll in a plan through the exchange, although Connecticut implemented a similar provision starting in 2019, and DC, Maine, Maryland, and New Jersey have added similar provisions since then.

Under federal ACA rules, a 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, they noted in February 2015 that they had opted not to include pregnancy as a qualifying event.

SEP for victims of domestic violence or spousal abandonment

As of April 15, 2016, victims of domestic violence or spousal abandonment, along with their dependents, are eligible for a special enrollment period during which they can obtain coverage through NY State of Health. If they’re eligible for the Essential Plan, Child Health Plus, or Medicaid, enrollment is available year-round anyway; but if not, they have an opportunity to purchase a QHP outside of open enrollment.

Carriers cannot impose a time limit on when the domestic violence or spousal abandonment occurred, nor can they “require any additional proof of eligibility or apply overly burdensome requirements on applicants seeking to use the special enrollment period.”

This is consistent with the regulations HHS established that allow victims of domestic violence or spousal abandonment to enroll in a plan through the exchange outside of open enrollment.

NY's CO-OP plans terminated November 30, 2015

On September 25, regulators announced that Health Republic of New York, an ACA-created CO-OP, would cease sales and begin winding down its operations. The CO-OP was the fourth CO-OP nationwide to succumb to the challenging market conditions under which they began their operations (by early November, 12 CO-OPs had failed).

Health Republic of NY had about 87,000 effectuated individual enrollments – roughly 20 percent of the individual market in the state.  They also had about 79,000 members in the small group market. Initially, state regulators said that existing members could keep their plans until December 31. But on October 30, just two days prior to the start of open enrollment, the NY Department of Financial Services (NYDFS) and NY State of Health announced that the financial situation at Health Republic of NY is worse than had previously been reported. As a result, existing policies were terminated at the end of November, and enrollees had to secure new coverage for December, in addition to selecting coverage for 2016.

Enrollees who didn’t pick a new plan for December were automatically enrolled in a replacement plan that provided the closest level of benefits to the Health Republic plan the member had in 2015 (there was also an option to opt out of this). NY State of Health announced that Fidelis, Excellus, and MVP had agreed to accept auto-renewals of Health Republic members who hadn’t selected a new plan by the third week of November. The members were assigned to one of the three replacement carriers based on their county of residence. The three carriers had also agreed to credit Health Republic members for any out-of-pocket costs incurred during the first 11 months of the year.

Health Republic was priced far lower than most other carriers offering plans through NY State of Health in 2015. A navigator in Rochester explained that “Health Republic came in at the lowest price in each of the medal (sic) levels, almost by half. It is going to be a challenge for (consumers) to pick a new plan in an insurance program that is going to be more expensive.” But those low premiums were ultimately the cause of the carrier’s demise; premiums simply weren’t high enough to cover claims.

New York health insurance exchange links

NY State of Health

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)

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Learn about health insurance coverage options in your state.

Our state guides offer up-to-date information about ACA-compliant individual and family plans and marketplace enrollment; Medicaid expansion status and Medicaid eligibility; short-term health insurance regulations and short-term plan availability; and Medicare plan options.

Other types of health coverage in New York

Short-term health insurance is not sold in New York.

Over 7.3 million New Yorkers enrolled in Medicaid; more than 2.2 million are covered under Medicaid expansion.

New York's Medigap regulations are among the strongest in the country.

Find affordable individual and family plans, small-group, short-term or Medicare plans.

Eligibility for Medicare Savings Programs in New York are based only on income, without any asset limits.

Learn about adult and pediatric dental insurance options in New York, including stand-alone dental and coverage through NY State of Health.

Would love your thoughts, please comment.x