- New York expanded Medicaid under the ACA, but the state’s pre-ACA eligibility guidelines were already generous.
- Medicaid expansion covers more than 2 million New Yorkers.
- New York Medicaid relies on managed care, and 19 insurers offer plans.
Medicaid expansion in New York
New York has long been a healthcare reform front-runner, creating a guaranteed issue individual health insurance market decades ahead of the Affordable Care Act (ACA), and also expanding Medicaid to cover many low-income parents and childless adults long before the ACA reformed the nation’s health insurance system. The state accepted the ACA’s provision to use federal funding to expand Medicaid as of January 1, 2014, and between the fall of 2013 and August 2018, the state’s total Medicaid enrollment grew by 14 percent, to nearly 6.5 million people. And New York State of Health, the state-run health insurance exchange, reported that nearly 3 million of those enrollees were enrolled via the exchange as of 2018.
As of 2016, New York’s Medicaid expansion was covering more than 2 million people. But New York’s eligibility guidelines were already so generous that fewer than 286,000 of those people were newly eligible as a result of the ACA’s expansion of Medicaid. The rest — nearly 1.8 million people — were already eligible for Medicaid prior to 2014 under New York’s rules. But the federal government pays the bulk of the cost for the entire Medicaid expansion population (the federal share of the cost will never drop below 90 percent). So the ACA’s expansion of Medicaid has been particularly beneficial to New York from a financial perspective.
For New York Medicaid enrollees who continue to be eligible based on pre-ACA guidelines, the state and federal government split the cost (since NY is a relatively wealthy state, they receive the lowest possible federal match, which is 50 percent). The state spent 27 percent of its revenue on Medicaid in 2016 (in addition to federal funding), and is consistently the state that spends the largest share of its revenue on Medicaid.
New York has the majority of their Medicaid population enrolled in managed care programs, under an 1115 waiver that dates back to 1997. In late 2016, CMS renewed the waiver, extending it out to 2021. As of 2018, there were 19 private insurers offering Medicaid coverage in the state, and 16 providing CHIP coverage.
Governor pushed back against GOP efforts to repeal the ACA
In January 2017, as President Trump was poised to take office and it was clear that GOP lawmakers were going to push hard for ACA repeal, New York Governor Andrew Cuomo, announced that 2.7 million New Yorkers were at risk of losing coverage if the ACA was repealed and not replaced with something equally robust, and that the state budget impact would be $3.7 billion. Ultimately, the ACA survived the legislative onslaught in 2017, there was no significant effort to repeal the law in 2018, and Democrats gained control of the US House in the 2018 election, making the ACA fairly safe for the next couple years.
But in 2017, that wasn’t the case, and New York’s continued federal Medicaid funding was in question. Although most of the state’s Medicaid enrollees were already eligible under New York’s pre-2014 guidelines, the state estimated that 1.9 million Medicaid enrollees would have lost access to Medicaid if the ACA had been repealed. That’s because the state was using 1115 waivers to expand coverage eligibility in the years prior to ACA implementation, and the federal government was splitting the cost with the state as called for in the waivers.
But those waivers expired after the ACA’s Medicaid expansion was implemented. If the ACA’s Medicaid expansion had been repealed, eligibility would have reverted to much lower thresholds: parents with dependent children would have been covered with income up to 94 percent of the poverty level (which is still much more generous than most states absent the ACA’s Medicaid expansion), and childless adults wouldn’t have been eligible at all. The state would have been allowed to spend their own money to extend those guidelines, but it would have been fiscally challenging without the federal match.
Medicaid expansion history in NY
As the ACA was written, it called for expanding Medicaid to 138 percent of poverty in every state. In 2012, however, the Supreme Court ruled that states could not be penalized for opting out of Medicaid expansion, and 14 states have not yet taken any steps to expand their Medicaid programs (five other states had not yet expanded their programs as of 2018, but were on track to do so in 2019: Virginia (where expansion takes effect in January 2019), Maine, Nebraska, Idaho, and Utah). Fortunately for New York’s residents, hospitals, and economy, the state further expanded Medicaid under the ACA.
In 2000, New York began implementing Family Health Plus, which was designed to insure up to 600,000 of the state’s low-income working adults. The state’s existing Medicaid program covered childless adults with incomes up to 50 percent of the poverty level, and Family Health Plus expanded coverage up to 100 percent of poverty. For parents with dependent children, the existing eligibility rules allowed Medicaid coverage up to 75 percent of poverty level, and Family Health Plus increased that threshold to 150 percent.
New York’s progressive stance on access to health care meant that much of the state’s low-income population was already eligible for Medicaid or Family Health Plus for many years prior to the ACA. It was a perfect fit for the state to accept the ACA’s provision to utilize federal funding to expand Medicaid to everyone with incomes up to 138 percent of poverty.
New York went a step further than most other states, and implemented the ACA’s Basic Health Program, which covers people with income a little too high for Medicaid. The Essential Plan became available in January 2016, and covers New York residents with income up to 200 percent of the poverty level. Premium and out-of-pocket costs for this population are much lower than they would be on qualified health plans in the exchange if the Basic Health Program were not in place. 738,851 New York residents were enrolled in The Essential Plan as of 2018.
Who is eligible?
Adults in New York with incomes up to 138 percent of poverty level are now eligible for Medicaid. Pregnant women and children under the age of one are eligible with an income of up to 218 percent of poverty level (for Medicaid eligibility determinations, a pregnant woman counts as two people for household income calculations).
Children from age one to eighteen are eligible for Medicaid with a household income up to 149 percent of poverty, but the state also has separate CHIP (Children’s Health Insurance Program) coverage available for children with household incomes up to 400 percent of poverty level – the highest threshold in the country.
How do I apply?
Family Health Plus stopped taking new enrollments at the end of 2013, and applicants are now directed to the state-run exchange (NY State of Health), where they can enroll in the streamlined and expanded Medicaid program (income limits for eligibility). Most people will apply through NY State of Health, but some enrollees will need to use their Local District Social Services Office instead
CHIP and Medicaid enrollment can both be completed through New York’s state-run exchange, NY State of Health. There is no open enrollment period for Medicaid or CHIP – anyone who qualifies can enroll at any time.
How many people have enrolled?
In an enrollment report published in August 2016, NY State of Health reported that 1,966,920 people had enrolled in Medicaid through the exchange by January 31, 2016. The total includes 1.74 million people who had renewed coverage for 2016, along with 223,115 who were new enrollees starting in 2016.
In an enrollment report published in January 2017, NY State of Health announced that Medicaid enrollment through the exchange had reached 2.33 million by December 24, 2016. In addition, 285,627 people had enrolled in Child Health Plus.
And in the 2018 enrollment report, Medicaid enrollment stood at 2,965,863, and CHIP enrollment stood at 374,577.
Average monthly enrollment was 5,678,417 in late 2013, and had grown to 6,491,361 by August 2018 — a net increase of 14 percent, or about 813,000 people. The net increase is far lower than the total number of people who have enrolled, because while new enrollees join the Medicaid program, existing enrollees transition off if their income increases or they obtain coverage elsewhere.
During the 2016 open enrollment period, 96 percent of the people who were newly enrolled in Medicaid through NY State of Health reported that they were uninsured prior to enrolling (as opposed to just 57 percent of the people who were newly enrolled in subsidized private plan QHPs through the exchange). Medicaid has clearly played an important role in reducing New York’s uninsured rate from 10.7 percent in 2013, to below 5 percent in 2017.
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.