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New York health insurance marketplace 2022 guide
Open enrollment for 2022 continues in NY through the end of the COVID public health emergency (at least mid-April 2022)
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 average rate increase of 3.7% for 2022, which was (as usual) quite a bit smaller than the average increase proposed by the insurers.
The open enrollment period for 2022 coverage has been extended through the end of the COVID public health emergency. Over 219,215 people have enrolled in private individual market plans through the New York exchange during open enrollment for 2022 coverage.
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 2022. (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 2022 (this is New York’s Basic Health Program — details below; availability varies from one county to another), and nine 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).
For 2022 coverage, there are twelve insurers that offer exchange plans in New York:
- Capital District Physicians’ Health Plan (CDPHP)
- Emblem (Health Insurance Plan of Greater New York)
- Excellus Health Plan
- Fidelis (New York Quality Health Care Corp. — owned by Centene as of July 2018)
- 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
- 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 2022, there are 15 insurers that participate in the exchange (some insurers offer plans under multiple names; the state has clarified that there are 12 distinct insurers offering plans for 2022).
- insurer participation by county in 2020
- insurer participation by county in 2021
- insurer participation by county in 2022
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 for 2022 coverage initially ran from November 16, 2021 through January 31, 2022. But in mid-January, New York State of Health announced that open enrollment would continue until the end of the COVID public health emergency. The public health emergency was extended in mid-January; these extensions last for 90 days at a time, so it will continue through at least mid-April 2022.
The COVID public health emergency has changed New York’s enrollment window. But even without COVID, New York’s enrollment window differs from most other states. Open enrollment begins in the rest of the country on November 1, but it didn’t start until November 16 in New York. And New York’s normal deadline is later than most other states, giving people until the end of January to enroll in coverage (in most states, the deadline is January 15).
After open enrollment eventually ends, a qualifying event will be necessary to enroll in individual/family coverage in New York. However, enrollment in Medicaid, Child Health Plus, and the Essential Plan is available year-round to anyone eligible, without the need for a qualifying event.
In New York, the overall weighted average rate increase for 2022 amounted to 3.7%, which is 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 has 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.
Metro Plus was the only insurer with an approved rate change equal to what they proposed. Approved rates for all of the other insurers were lower 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): 7% increase. CDPHP has 6,725 enrollees.
- Emblem (Health Insurance Plan of Greater New York): 1.2% increase. Emblem has 12,546 members.
- Health Plus HP (formerly Empire): 0.4% increase. Health Plus has 14,719 members.
- Excellus Health Plan: 4.5% increase. Excellus has 23,813 members.
- Fidelis (New York Quality Health Care Corp. — owned by Centene as of July 2018): 0.1% decrease. Fidelis has 90,238 members.
- Healthfirst PHSP: 9.7% increase. Healthfirst PHSP has 31,414 members.
- Highmark Western and Northeastern New York (formerly HealthNow): 6.2% increase. Highmark has 9,882 members.
- Independent Health Benefits Corporation: 4.4% decrease. IHBC has 4,520 members.
- Metro Plus Health Plan: 3.9% decrease. (approved as proposed). Metro Plus has 8,047 members.
- MVP Health Plan: 8.5% increase. MVP has 28,792 members.
- Oscar: 7.5% increase. Oscar has 23,116 members.
- UnitedHealthcare of New York: 7.1% increase. United has 7,430 members.
In addition, Healthfirst Insurance Company, which offers individual market plans only outside the exchange, is increasing average premiums by 8.8% for 2022 (down from a proposed average rate increase of 33.3%).
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.
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.
By the end of May 2021, New York State of Health reported that it had more than 6 million enrollees. Most are enrolled in Medicaid, the Essential Plan, or Child Health Plus, with only 220,000 enrolled in qualified health plans (QHPs, which are private health plans for people who don’t qualify for Medicaid, Child Health Plan, or the Essential Plan).
Enrollment in QHPs was lower than it had been in 2020, when 272,948 people had enrolled in QHPs during open enrollment. But enrollment in Medicaid, Child Health Plan, and the Essential Plan were all higher than they had been in prior years, due in large part to the pandemic and the resulting job losses and income reductions. It’s also important to note that nationwide, states are not disenrolling people from Medicaid until after the pandemic emergency period ends, resulting in higher Medicaid enrollment than we’d otherwise see.
For perspective, here’s a look at QHP enrollment in New York State of Health since 2014:
- 2014: 370,451 people enrolled in QHPs
- 2015: 408,841 people enrolled in QHPs
- 2016: 271,964 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.]
- 2017: 242,880 people enrolled (plus 665,324 people enrolled in The Essential Plan)
- 2018: 253,102 people enrolled in QHPs (plus 738,851 people enrolled in The Essential Plan)
- 2019: 271,873 people enrolled in QHPs (plus 790,152 people enrolled in The Essential Plan)
- 2020: 272,948 people enrolled in QHPs (plus 796,998 people enrolled in The Essential Plan)
- 2021: 215,889 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 has been 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: 219,215 people had enrolled in QHPs by January 15. But as noted above, New York’s open enrollment period for 2022 coverage continues until the COVID public health emergency ends, which will be at least mid-April 2022.
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).
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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 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 were satisfied with their coverage, and three-quarters of the exchange’s enrollees would recommend NY State of Health to other people.
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 considerably 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
- A higher actuarial value requirement than the federal government imposes. (And as of 2019, New York requires silver plans to have an actuarial value that can only vary between 70% and 72%, not counting cost-sharing reduction variations of silver plans. Under federal rules, silver plans can have an actuarial value between 66% and 72%, but New York is no longer allowing a negative de minimis variation for silver plans.
- Allowing a special enrollment period for pregnant women (Connecticut, New Jersey, Maine, and DC are the only other places that offer this),
- 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 2022 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 is under consideration in 2022 that would reduce this cap to $30.
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 is A.6058 and S.5474, although neither has 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.
Although coverage is less expensive in New York than it was prior to 2014, there are still people — mainly those who earn only slightly too much to be eligible for subsidies in the exchange — who struggle to afford health insurance. Two bills were introduced in the 2019 legislative session (A.1443, with an effective date of January 2019, and A.5203, which is identical except for a January 2020 effective date) that would have provided a 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.
The Essential Plan debuted in 2016. By 2021, enrollment had grown to roughly 1 million
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.
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.
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).
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 November 2016, enrollment had grown to 565,000 people. By early 2019, there were 790,152 people enrolled in the Essential Plan, 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 the end of August 2021, enrollment in the Essential Plan stood at nearly 914,000. By late 2021, there were “approximately 1 million” people enrolled in Essential Plan coverage.
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 now a qualifying event
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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
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