Frequently asked questions about health insurance
coverage options in New York
New York’s state-run exchange is called New York State of Health. It is one of the most robust exchanges in the country, with 15 carriers offering individual market plans for 2021.
Open enrollment in New York for 2021 coverage has been extended through December 31, 2021 in New York – giving residents the entire year to enroll in coverage – in order to address the ongoing COVID pandemic and allow residents to take advantage of the premium subsidy enhancements available as a result of the American Rescue Plan.
New Yorkers already enjoyed a longer open enrollment period than residents of most other states, with an enrollment window that was initially slated to continue through January 31, 2021 – twice as long as the enrollment window that applied in states that use HealthCare.gov (New York has consistently allowed an enrollment period of at least three months).
Although people normally need to have a qualifying event in order to enroll in coverage or make a change to their plan outside of the open enrollment period (both on-exchange and directly through an insurance company), New York has been allowing uninsured residents continuous access to health coverage since soon after the pandemic began.
Open enrollment for 2020 health plans had already ended by the time the COVID pandemic struck, but New York quickly moved to open a special enrollment period in order to increase healthcare access and affordability for people facing the health crisis without health insurance. The enrollment window has been extended repeatedly, and is currently slated to run through December 31, 2021 (and since early in 2021, New York State of Health has clarified that this is an extension of open enrollment as opposed to just an opportunity for uninsured residents to sign up for coverage).
New York State of Health is one of the most robust exchanges in the country, with 15 carriers offering individual market plans for 2021. There are also 14 insurers offering Essential Plan coverage in 2021 and 14 insurers offering small business plans through NY State of Health’s SHOP exchange.
Enrollment in NY State of Health – including QHPs (private plans), the Essential Plan, Medicaid, and Child Health Plus – reached more than 4.9 million by early February 2020, when open enrollment ended. That was an increase of 150,000 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 273,000 were enrolled in QHPs for 2020).
By mid-2021, enrollment in QHPs had dropped to 220,000, but total enrollment had grown to more than 6 million, with Medicaid enrollment increasing to more than 4.5 million, and enrollment in the Essential Plan growing to 893,000 people. The enrollment growth in Medicaid, CHP, and the Essential Plan are not surprising, given the ongoing COVID pandemic and the widespread income losses that have applied as a result.
Inflation-adjusted premiums in New York’s individual market are still lower 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.)
For 2021, New York regulators approved an average rate increase of just 1.8% for individual market plans, which is the smallest percentage rate increase in the last decade.
For 2022 coverage, New York’s individual/family insurers have proposed an average rate increase of 11.2%. And in the small group market, insurers have proposed an average rate increase of 14%. But the New York Department of Financial Services is likely to approve smaller rate increases, as they consistently approve rates that are smaller than the insurers propose.
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 some of the major market stabilization components that the ACA later enacted:
- There were no open enrollment periods (people could buy coverage anytime they wanted).
- There were no premium subsidies, so people had to pay full price for individual market coverage.
- There was no individual mandate, so people could wait until they were in need of care before purchasing health insurance (note that this provision in the ACA was only enforced with a penalty for non-compliance through 2018; the individual mandate is still in effect, but there is no longer a penalty for non-compliance).
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 individual mandate (although the penalty for non-compliance was eliminated after the end of 2018), limited enrollment period, and premium subsidies to make coverage affordable for middle-class enrollees. As a result, premiums dropped significantly in 2014, and have remained below the level they were at in 2013.
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% of the poverty level.
BHPs are allowed under the ACA, but only New York and Minnesota opted to create them.
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.
New York 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.
New York opted to implement Medicaid expansion under the Affordable Care Act, and Medicaid/CHIP enrollment in New York increased by 16% from the fall of 2013 to November 2020. In early 2020, Medicaid/CHIP enrollment had been just 7% higher than it had been in 2013, but the COVID pandemic has resulted in increased Medicaid enrollment nationwide. This is due to widespread job/income losses, combined with federal rules that prevent states from terminating Medicaid coverage during the pandemic emergency period.
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% to 200% 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 more than 885,000 people by 2021, and continues to have premiums of $20/month or less.
Read more about Medicaid expansion 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 insurance plans, despite federal short-term health insurance rules being relaxed in 2018.
Read more about short-term health insurance in New York.
- Community Health Advocates
- Health Insurance Information, Counseling and Assistance (HIICAP) — Medicare counseling and information
- New York Department of Financial Services
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 been helpful in smoothing out some rough edges in the New York insurance market, and since implementing Obamacare, the state has continued upon these improvements.
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 following health care reform provisions apply in New York:
IVF coverage (but only for large group plans): New York’s 2020 budget included 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.
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, the carrier was 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.