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New York health insurance

New York has long been a leader in health care reform

Health insurance in New York

New York overview: Taking advantage of all the ACA has to offer

State legislative efforts to preserve or strengthen provisions of the Affordable Care Act

New York is one of the states fighting the hardest to preserve the Affordable Care Act’s gains. See the actions New York has taken.

New York has fully embraced the Affordable Care Act (ACA). The state expanded Medicaid, established its own health insurance exchange, and even created a Basic Health Program (BHP) for people who earn more than the Medicaid eligibility threshold, but not more than 200 percent of the poverty level. BHPs are allowed under the ACA, but only New York and Minnesota opted to create them.

New York’s health insurance marketplace

The health of New York’s state-based exchange, NY State of Health remains strong heading into 2020. The exchange has robust insurer participation, and premiums are still lower for 2019 than they were in 2013. (That’s not the case in most states, but New York had guaranteed-issue coverage long before the ACA, but without a mandate requiring people to buy coverage and without premium subsidies for middle-class enrollees. As a result, coverage was expensive in New York pre-2014.)

Enrollment in NY State of Health – including QHPs (private plans), the Essential Plan, Medicaid, and Child Health Plus – reached more than 4.7 million by the end of January 2019 (when open enrollment ended for QHPs). That was an increase of 435,000 over the prior year’s total enrollment (the majority of NY State of Health’s enrollees are in Medicaid, the Essential Plan, and CHP; only about 272,000 were enrolled in QHPs for 2019).

Open enrollment for 2020 health plans: November 1, 2019 through January 31, 2020

As they have done in previous years, New York State of Health has extended open enrollment for 2020 individual market health coverage. It will run from November 1, 2019 to January 31, 2020. That’s twice as long as the open enrollment period that applies in states that rely on

New York is a progressive state that embraced health care reform decades ahead of most of the rest of the country. The Affordable Care Act has smoothed out some rough edges in the New York insurance market, and since implementing Obamacare, the state has continued upon these improvements.

A few states have implemented their own individual mandates for 2019 and beyond, although New York is not one of them. But Governor Cuomo took action in early 2017 to protect New York residents’ access to birth control and abortion coverage, regardless of the future of the ACA. The Governor also worked to ensure continued robust insurer participation in the individual market, and ongoing access to essential health benefits. Lawmakers continue to consider a single-payer system, and although single-payer legislation has passed in the Assembly numerous times, it has always fallen short in the Senate (the 2019 single payer bills are A.5248 and S.3577).

New York health insurance regulations go well beyond the ACA and most other states

  • IVF coverage (but only for large group plans): New York’s 2020 budget includes a requirement that state-regulated large group health plans cover IVF. To clarify, this applies to non-self-insurance plans with more than 100 employees (plans with up to 100 employees are considered “small group” in New York, and self-insured plans are regulated by the federal government under ERISA, rather than state laws and regulations). The state considered the possibility of requiring individual and small group health plans to cover IVF, but that would have been costly for the state. Under the ACA, if a state adds a new mandated benefit for individual and small group plans — above and beyond essential health benefits — after the end of 2011, the state has to cover the added cost for that coverage by sending payments to the enrollees or to the insurer. This ACA rule prevents states from adding numerous additional mandated benefits that drive up the cost of coverage and thus drive up the federal government’s cost for premium tax credits. But essential health benefit requirements don’t apply to large group plans, so the state isn’t on the hook for covering the added cost of this new mandated benefit. The new budget does require all plans — including individual and small group plans — to cover medically necessary fertility preservation (for example, retrieving and freezing eggs or sperm before chemotherapy), but this benefit has much lower utilization than IVF and thus has a much smaller effect on premiums.
  • Contraceptive coverage: New York has implemented regulations that mirror the ACA’s contraceptive coverage mandate for women, and also allow women to obtain up to 12 months of birth control at a time. Legislation enacted in 2019 requires state-regulated health plans to cover all forms of FDA-approved contraception (including contraception for men) without any cost-sharing.
  • Surprise billing protections: New York implemented regulations in 2015 that protect consumers from surprise balance billing.
  • Pregnancy SEP: Pregnancy has been a qualifying event in New York since 2016.
  • Higher MLR standards: New York requires insurers to spend at least 82 percent of premiums (for individual and small-group coverage) on medical costs, which is more stringent than the federal requirement of 80 percent.
  • Regulation to keep insurers in the marketplace: In 2017, New York implemented regulations that prevent insurers that withdraw from the marketplace from having state contracts for the Medicaid, CHP, or Essential Plan programs. [Although Affinity stopped offering marketplace plans at the end of 2017, they were allowed to continue to participate in the Medicaid, CHP, and Essential Plan programs because it was the state’s decision — not Affinity’s decision — to have the insurer withdraw from the marketplace due to their financial situation.]
  • Premium restrictions: New York does not allow individual or small group premiums to vary based on age or tobacco use. Under the ACA, premiums for individual and small group health coverage can be up to three times higher for older enrollees versus younger enrollees, and up to one-and-a-half times higher for tobacco users. But New York doesn’t allow either of these rating adjustments.
  • Short-term health plans: New York does not allow the sale of short-term health insurance plans. This helps to protect the health insurance risk pool for everyone, as it prevents healthy people from dropping out of the real insurance pool and opting for lesser benefits (at a lower cost), leaving an overall sicker pool of people in the ACA-compliant risk pool.
  • Definition of “small group”: New York is one of just four states where businesses with 51 to 100 employees purchase plans in the small-group market (in most states, businesses that size buy coverage in the large-group market, which is not subject to as many ACA regulations as the small group market). Although that was originally intended to be the case in every state as of January 2016, Congress reversed course in late 2015 with the PACE Act (HR1624), which kept the definition of “small group” at businesses with a maximum of 50 employees. But New York had passed its own law in 2013 to align the definition of small group with what was called for in the ACA, calling for the definition change in 2016. And the PACE Act had no impact on New York’s law, so businesses with up to 100 employees can use NY State of Health’s SHOP exchange.
  • No transitional/grandmothered plans: New York declined President Obama’s offer to allow health insurance plans scheduled for year-end termination to be extended into 2014. So there are no “grandmothered” plans in New York.

2020 exchange carriers

New York has a very robust individual health insurance market, with 12 carriers offering plans in the exchange, and two that offer plans only outside the exchange. All of them will continue to offer coverage for 2020. They initially proposed an average rate increase of 8.4 percent, but revised it to 9.2 percent. NYDFS reviews rates before approving them, and as they’ve done in each of the previous years, they approved lower-than-proposed rates for 2020. The average approved individual market rate increase for 2020 ended up at 6.8 percent. Details about approved average rate changes for each plan are available here. The following insurers offer individual-market plans in New York’s exchange:

  • Capital District Physicians Health Plan
  • Health Plus HP (Empire BlueCross and Empire Blue Cross Blue Shield)
  • Excellus (Excellus Blue Cross Blue Shield in Central New York and Univera in Western New York)
  • Fidelis Care (New York Quality Health Care Corp.)
  • Health Insurance Plan of Greater New York (EmblemHealth)
  • Healthfirst New York
  • HealthNow New York, Inc. (BlueShield of Northeastern New York, and BlueCross BlueShield of Western New York)
  • Independent Health
  • MetroPlus Health Plan
  • MVP Health Plan, Inc.
  • Oscar Insurance Corporation
  • United Healthcare of New York, Inc

Two insurers – Crystal Run Health Plan and HealthFirst Insurance Company – offer off-exchange plans in 2019, but Crystal Run will not offer coverage in 2020.

In the small-group market – where more than a million New Yorkers get their health coverage – employers with up to 100 employees can purchase ACA-compliant plans. With the exception of Fidelis, all of the individual-market carriers offer small-group plans, in addition to Aetna Life, Oxford, and some additional divisions of a few of the companies that offer individual market plans.

Seventeen New York health carriers offer plans under the state’s Basic Health Program. Also known as the “Essential Plan,” this coverage is for people with incomes up to 200 percent of the federal poverty level and does not include a deductible or premium. New York and Minnesota are the only states that have established BHPs. As of 2019, there are more than 790,000 people enrolled in the Essential Plan.

New York State of Health enrollment tops 4.7 million, including Medicaid and Child Health Plus

Open enrollment for 2019 coverage followed the same November to January schedule, ending on January 31, 2019. In May 2019, New York State of Health published an enrollment report, noting that total enrollment in public and private plans through the exchange (including Medicaid, the Essential Plan, Child Health Plus, and private plans) had reached more than 4.7 million people by the end of January, which was an increase of about 7 percent compared with the year before (although most of this was simply a shifting of people from the legacy Medicaid enrollment system to the NY State of Health Medicaid enrollment system, and a change that allows small businesses to enroll in SHOP plans directly through the insurers).

At the end of the open enrollment period for 2019 coverage, enrollment was as follows:

  • 271,873 people had enrolled in private health plans, aka QHPs.
  • 790,152 people had enrolled in the Essential Plan (a Basic Health Program for people with income up to 200 percent of the poverty level)
  • 417,753 people had enrolled in Child Health Plus
  • 3,287,846 people had enrolled in Medicaid

New York’s QHP enrollment numbers dropped in 2016, which was due in part to the Essential Plan becoming available. The Essential Plan also reduced the percentage of QHP enrollees who received premiums subsidies, dropping from 70 percent in 2015 to 55 percent in 2016. That had increased to 59 percent by 2018.

Read more about the New York health insurance marketplace.

Health Republic CO-OP closed in November 2015

One of the available plans during the first two open enrollment periods was an ACA-created Consumer Oriented and Operated Plan (CO-OP). Under the ACA, the federal government awarded $2 billion in start-up funding to CO-OPs in 22 states.

In New York, the CO-OP was Freelancers Health Service Corporation (also known as Health Republic), which received $174 million in federal funding. The CO-OP was highly successful in terms of enrollments, garnering about 20 percent of the individual market in New York in both 2014 and 2015. However, it struggled financially, and in September 2015, state and federal regulators shut down the CO-OP.

Learn more about the Affordable Care Act’s CO-OPs.

New York Medicaid/CHIP enrollment

Medicaid/CHIP enrollment in New York increased by 15 percent from the fall of 2013 to March 2019. The state’s acceptance of federal funding to expand Medicaid eligibility to 138 percent of poverty has played a significant role in New York’s Obamacare success.

The ACA called for Medicaid expansion nationwide, but in 2012 the Supreme Court ruled that states could opt out, and 16 states have not yet expanded their Medicaid programs (Nebraska and Idaho have agreed to expand Medicaid, but with adjustments that require federal approval — so enrollment in their Medicaid expansion programs is not yet available).

During the first open enrollment period, the Kaiser Family Foundation estimated that about 43 percent of the 2.2 million non-elderly uninsured residents in New York would be eligible for Medicaid or CHIP under the expanded eligibility guidelines created by the ACA. Eligible applicants can enroll in New York Medicaid year-round, so total enrollment has continued to increase, further lowering the uninsured rate in New York.

The addition of the Essential Plan in 2016 helped to smooth the transition between Medicaid and private health plans. People with income a little too high for Medicaid (139 percent to 200 percent of the federal poverty level) qualify for the Essential Plan instead of having to enroll in a subsidized private plan. Enrollment in the Essential Plan had reached 790,000 people by 2019, and continues to have premiums of $20/month or less in 2019.

Read more about Medicaid expansion in New York.

Short-term health insurance in New York

The state of New York requires health plans to be guaranteed renewable and cover essential health benefits. As a result of those two regulations, the state does not allow the sale of short-term health plans, despite new federal short-term rules.

Read more about short-term health insurance in New York.

How Obamacare has helped New York

In most of the United States, individual health insurance was medically underwritten prior to 2014, meaning that people with pre-existing conditions were often unable to purchase private coverage. But in New York, former Gov. Mario Cuomo signed a law in 1992 that required all policies in the state to be guaranteed issue, regardless of medical history. They also switched to a community rating system, with the same premiums charged for everyone, regardless of age.

Although the 1992 law was heralded by consumer advocates as a victory, it lacked two of the major market stabilization components that the ACA has now enacted. There were no open enrollment periods (people could buy coverage anytime they wanted), and there was no individual mandate, so people could wait until they were in need of care before purchasing health insurance.

Two decades later, health insurance premiums in New York were the highest in the nation, and coverage options were very limited, with few carriers choosing to participate in the market in New York.

The ACA brought much-needed changes to New York, keeping the guaranteed issue model (and in New York, coverage is still community-rated), but adding the vitally important individual mandate, limited enrollment period, and premium subsidies to make coverage affordable for middle class enrollees. As a result, the rates that the state approved for 2014 were an average of 50 percent lower than 2013 rates, and that was before factoring in the subsidies that 60 percent of New York State of health’s QHP enrollees receive (QHP stands for qualified health plan, which is another word for the private health plans offered for sale in the exchange, as opposed to Medicaid, the Essential Plan, and Child Health Plus). Officials in NY noted that 2018 premiums continue to be more than 50 percent lower than pre-2014 rates, despite modest rate increases each year.

In 2013, about 10.7 percent of New York residents were uninsured, according to US Census data. By 2017, that number had fallen by nearly half, to 5.7 percent. At that point, the average uninsured rate across the US was 8.7 percent, and just 13 states had uninsured rates lower than New York’s.

NY State of Health enrolled more than 4.7 million people during the open enrollment period for 2019 coverage, including enrollments in the Essential Plan, Child Health Plus, Medicaid, and individual qualified health plans.  Enrollments continue year-round for Medicaid, Child Health Plus, and the Essential Plan.

New York’s lawmakers and the Affordable Care Act

In 2010, New York’s U.S. senators (Democrats Kirsten Gillibrand and Charles Schumer) both voted yes on the ACA. In the U.S. House, 24 Democrats voted yes, while two Republicans and two Democrats (Michael McMahon and Michael Arcuri) voted no. Schumer and Gillibrand are still in the Senate. Both McMahon and Arcuri were replaced by new Democrats in 2013. The U.S. House delegation from New York currently consists of nine Republicans and 17 Democrats, with one vacant seat. We have a summary of how each of them has voted on key health care reform legislation.

In New York’s state legislature, there’s a strong Democratic majority in the House. Although the Senate also technically has a Democratic majority, nine Democrats caucus with the Republicans, including eight who belong to the Independent Democratic Conference (IDC). This has allowed Republicans to retain control of the state Senate, although the IDC members have signed on as co-sponsors of the legislation that would create a single-payer system in New York.

Democratic Governor Andrew Cuomo is an ardent supporter of the ACA, saying in 2012, “We look forward to continuing to work together with the Obama administration to ensure accessible, quality care for all New Yorkers.” He has continued with that support, moving ahead in January 2017 to implement regulations that protect contraceptive and abortion coverage at the state level, regardless of the future of the ACA under the Trump Administration.

The state has been fully on-board with ACA implementation from the start, opting for a state-run exchange (NY State of Health) and expanding Medicaid to cover residents with incomes up to 138 percent of poverty. The state was also only the second in the nation (after Minnesota) to implement the ACA’s provision to create a Basic Health Program, extending very low-cost health insurance (the Essential Plan) to residents with incomes up to 200 percent of the poverty level.

Medicare enrollment in New York

New York Medicare Medicare enrollment reached nearly 3.6 million enrollees in 2019 – almost 18 percent of the state’s population, which is consistent with the percentage of people enrolled in Medicare nationwide. As of 2016, about 85 percent of New York Medicare recipients qualify for coverage based on age alone, while the remaining 15 percent were on Medicare due to disability.

When it comes to spending, Original Medicare per-beneficiary spending in New York averaged $9,670 in 2016. That’s above the national average spending of $9,533.

Those who want additional benefits beyond what original Medicare offers can choose a Medicare Advantage plan instead of traditional coverage. In New York, 38 percent of Medicare recipients had Medicare Advantage plans as of 2017.

Medicare Part D plans are also an option for Medicare beneficiaries who want to stand-alone prescription drug coverage. In 2018, nearly 1.5 million New York beneficiaries had a stand-alone Rx plan.

New York health insurance resources

State-based health reform legislation

In 2014, New York lawmakers passed A.9205, the “Emergency Medical Services and Surprise Bills” law. This legislation took effect in 2015, and protects consumers in some circumstances from having to pay surprise balance bills when they’re treated by out-of-network providers at in-network facilities, or when they’re referred to an out-of-network provider by their in-network provider.

In 2019, New York enacted the Comprehensive Contraception Coverage Act, requiring health plans to cover the full range of FDA-approved contraceptives (including male contraception) with no cost-sharing.

New York lawmakers have tried for years to pass single payer legislation (here is the 2018 version of the legislation), but although it has passed the state Assembly for several years in a row, the Senate has not passed it. The 2019 versions of the legislation are A.5248 and S.3577.

At the bottom of this page, we have a summary of other recent New York bills related to healthcare reform.