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 12 carriers offering individual market plans for 2022.
Although New York typically has a 3.5 month open enrollment period (mid-November through the end of January), the open enrollment period for 2022 coverage has been extended in New York through the end of the federal COVID public health emergency period. This will be at least through mid-April 2022.
A qualifying event is not necessary to enroll during the extended enrollment window for 2022 coverage. But once the open enrollment period ends, a qualifying event will once again be necessary in order to enroll in coverage outside of open enrollment.
Enrollment in Medicaid, Child Health Plus, and the Essential Plan is available year-round to all eligible enrollees; a qualifying event is not necessary to enroll in these plans.
New York had also extended the enrollment window for 2021 coverage until the end of 2021, giving people a chance to sign up for coverage and take advantage of the newly enhanced premium subsidies made available by the American Rescue Plan.
New York State of Health is one of the most robust exchanges in the country, with twelve insurers that offer exchange plans for 2022:
- 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
Enrollment in NY State of Health – including QHPs (private plans), the Essential Plan, Medicaid, and Child Health Plus – reached more 6.3 million by September 2021. (The majority of NY State of Health’s enrollees are in Medicaid, the Essential Plan, and CHP; only about 237,000 were enrolled in QHPs at that point).
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 implemented an average rate increase of 3.7%. This was quite a bit smaller than the insurers had initially proposed, but the New York Department of Financial Services has consistently approved rate increases that are smaller than 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% 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 21% from the fall of 2013 to mid-2021.
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 (states receive additional federal Medicaid funding during the emergency period, but on the condition that enrollees’ coverage cannot be terminated).
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 roughly one million people by late 2021, and premiums were eliminated in 2021.
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.
Former 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.
Surprise billing protections: New York implemented regulations in 2015 that protect consumers from surprise balance billing. (Federal protections took effect in 2022, ensuring that people with self-insured coverage — which is not regulated at the state level — would also be protected 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, 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.
Caps on the cost of insulin: New York capped 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.