New York Health Insurance

 

Health insurance in New York

● New York has extended its special open enrollment period until the end of December 2020 to address the ongoing coronavirus pandemic.

● Open enrollment for 2021 coverage has been extended until January 31, 2020.

● New York operates its own health insurance market: NY State of Health.

● New York has long been a leader in health care reform and has enacted numerous consumer protection regulations.

● About 273,000 New York residents signed up for QHP 2020 through the state exchange; a further 797,000 New Yorkers are enrolled in the Essential Plan.

● New York adopted the Medicaid expansion in 2013. Medicaid enrollment is 7% higher than in 2013.

● New York does not allow the sale of short-term plans.

● 3.5 million New Yorkers are enrolled in Medicare.

This page is designed to provide useful resources for New York health consumers. We've included information about new York's health insurance (exchange) market and extended open enrollment period, as well as the state's extended covid-19 enrollment window for uninsured residents. We also cover the state's approach to Medicaid expansion, explain why short-term health plans aren't available in New York, and turn to Medicare coverage and enrollment, as well as state rules for Medigap plans. You'll also find a collection of health insurance resources for New York residents.

New York Overview: Take advantage of everything the ACA has to offer

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 earning more than the Medicaid eligibility threshold, but no more than 200 percent of the poverty level.

BHP is allowed under the ACA, but only New York and Minnesota have chosen to create them.

New York Health Insurance Marketplace

You can use the insurance market to sign up for health care and to see if your income level makes you eligible for subsidies or cost-sharing reductions (CSR) to help you pay monthly premiums and other expensive out-of-pocket expenses (such as a deductible or copay). The health insurance market is a good option for individuals or families who own a small business or are employed by an organization that does not provide health insurance coverage.

New York has a very successful state exchange, NY State of Health. New York's health insurance market has a solid insurance stake, with 12 insurers offering plans in 2020; note that not all plans offer services in all counties. And inflation-adjusted premiums in the New York individual market are still lower than in 2013. (That's not the case in most states, but New York had secured issuance 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 before 2014.)

For 2021, New York regulators have approved an average rate increase of just 1.8% for individual market plans, which is the smallest percentage rate increase in the last decade.

New York Health Enrollment, including QHPs (private plans), essential plan, Medicaid, and Child Health Plus, reached more than 4.9 million in early February 2020, when open enrollment ended. That was a 150,000 increase over the previous year's total enrollment (most New York State of Health enrollees are on Medicaid, essential plan, and CHP; only about 273,000 have been enrolled in QHPs by 2020).

Open enrollment period and dates in New York

Registration open in New York for 2021 coverage will run out from November 1, 2020 to January 31, 2021. This is twice the registration window that applies in states that use HealthCare.gov, but New York has consistently allowed a registration period of at least three months. Outside of that open enrollment period, residents need a qualifying event to sign up for coverage or make a change to their plan.

Coronavirus special enrollment period extended until December 31, 2020

New York State's open enrollment period for 2020 coverage ended on February 7, 2020 (which included a week-long extension; it was scheduled to end january 31). But the coronavirus pandemic began the following month, and New York quickly moved to open a special enrollment period in order to increase access to health care and affordability for people facing the health crisis without health insurance. The registration window has been extended repeatedly and is currently scheduled for December 31, 2020.

New York State's open enrollment period for 2020 coverage ended on February 7, 2020 (which included a week-long extension; it was scheduled to end January 31). But the coronavirus pandemic began the following month, and New York quickly moved to open a special enrollment period in order to increase access to health care and affordability for people facing the health crisis without health insurance. The registration window has been extended repeatedly and is currently scheduled for December 31, 2020.

New York is a progressive state that embraced health care reform decades earlier than most of the rest of the country. The Affordable Care Act has been useful in smoothing out some rough edges in the New York insurance market, and since the implementation of Obamacare, the state has continued to make these improvements.

Governor Cuomo was adopted in early 2017 to protect New York residents' access to birth control and abortion coverage, regardless of the future of the ACA. The Governor has also worked to ensure strong insurers' participation in the individual market and continued access to essential health benefits. Lawmakers continue to consider a single-payer system, and although single-payer legislation has been passed several times in the House, it has always been short in the Senate.

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

● IVF coverage (but only for large-group plans): New York's 2020 budget includes a requirement that the health plans of large, state-regulated groups 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 groups" in New York, and self-insured plans are regulated by the federal government under ERISA, rather than state laws and regulations). The state considered requiring individual and small-group health plans to cover IVF, but this would be costly for the state. Under the ACA, if a state adds a new benefit imposed for individual and small-group plans - beyond essential health benefits - after the end of 2011, the state must cover the additional cost of such coverage by sending payments to enrollees or insurers. This ACA rule prevents states from adding numerous additional benefits on warrants that increase the cost of coverage and thus increase the federal government's cost of premium tax credits. But essential health benefit requirements do not apply to large-group plans, so the state is not in danger to cover the additional cost of this new imposed benefit. The new budget requires all plans - including individual and small-group plans - to cover the medically necessary fertility preservation (e.g. recovery and freezing of eggs or sperm before chemotherapy), but this benefit has much less use than IVF and therefore has a much smaller effect on premiums.

● Contraceptive coverage: New York has implemented regulations that reflect the ACA's contraceptive coverage mandate for women and also allow women to get 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.

● SEP Pregnancy: Pregnancy has been a qualifying event in New York since 2016.

● Higher MLR standards: New York requires insurers to spend at least 82% of premiums (for individual and small-group coverage) on medical costs, which is stricter than the 80% federal requirement.

● Regulation to keep insurers on the market: In 2017, New York implemented regulations that prevent insurers withdrawing from the market from having state contracts for Medicaid, CHP, or Essential Plan programs. [Although Affinity stopped offering market plans at the end of 2017, they were allowed to continue participating 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 market because of their financial situation.]

● Premium restrictions: New York does not allow individual or small-group premiums to vary based on age or tobacco consumption. Under the ACA, premiums for individual and small-group health coverage can be up to three times higher for older enrollees than younger enrollees and up to a year and a half higher for tobacco consumers. But New York doesn't allow any of these rating adjustments.

● Short-term health plans: New York does not allow the sale of short-term health insurance plans. This helps protect the health insurance risk pool for everyone, as it prevents healthy people from leaving the real insurance pool and opting for lower benefits (at a lower cost), leaving an overall pool of people in the ACA-compliant risk pool.

● Definition of "small group": New York is one of only four states where companies with 51-100 employees buy plans in the small group market (in most states, companies that cut purchasing coverage in the large group market, which is not subject to as many ACA regulations as the small group market). Although it was originally supposed to be the case in every state starting in January 2016, Congress reversed course at the end of 2015 with the PACE Act (HR1624), which maintained the definition of "small group" at companies with up to 50 employees. But New York passed its own law in 2013 to align the definition of a small group with what was required in the ACA, calling for a change of definition in 2016. And the PACE Act has had no impact on New York law, so companies with up to 100 employees can use NY State of Health's SHOP exchange.

● No transitional plan/grandfather: New York rejected President Obama's offer to allow the extension of health insurance plans scheduled for the end of the year until 2014. So there are no "grandfather" plans in New York.

Medicaid expansion in New York

Medicaid in a health insurance option available to people on low or very low incomes or those with disabilities. Medicaid is a joint state and federal program. The federal government defines broad requirements and the state determines eligibility levels and manages the program. Some people qualify for both Medicaid and Medicare.

New York has chosen to implement Medicaid expansion under the Affordable Care Act, and enrollment in Medicaid/CHIP in New York has increased by 7% since the 2013 decline in January 2020 (down from a 15% increase in early 2019).

The addition of the Essential Plan in 2016 helped smooth out the transition between Medicaid and private health plans. People with a somewhat too high income 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. Essential plan membership had reached nearly 797,000 people by 2020 and continues to have premiums of $20/month or less.

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 these two regulations, the state does not allow the sale of short-term health insurance plans, despite new short-term federal regulations.

How Obamacare helped New York

In most of the United States, individual health insurance was medically underwritten before 2014, meaning that people with pre-existing conditions were often unable to purchase private coverage. But in New York, former Governor Mario Cuomo signed a law in 1992 that required all state policies to be guaranteed, regardless of medical history. They also switched to a community assessment 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 main market stabilization components that the ACA has now adopted. There were no open enrollment periods (people could buy coverage whenever they wanted), and there was no individual mandate, so people could wait until they needed care before buying 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 New York market.

The ACA brought much-needed changes to New York, keeping the issue model guaranteed (and in New York, coverage is still community-classified), but adding the individual mandate (though the non-compliance penalty was eliminated after the end of 2018), the limited enrollment period, and premium grants to make coverage accessible to middle-class enrollees. As a result, premiums fell significantly in 2014 and remained below the level they were at in 2013.

New York lawmakers and the Affordable Care Act

In 2010, U.S. Senators from New York (Democrats Kirsten Gillibrand and Charles Schumer) both voted yes to the ACA. In the 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 seat vacant. We have a summary of how each of them voted on key health care reform legislation.

In the New York State Legislature, there is a strong Democratic majority in the House. Although the Senate also technically has a Democratic majority, nine Democrats caucus with Republicans, including eight who belong to the Independent Democratic Conference (IDC). This allowed Republicans to retain control of the state Senate, although IDC members signed up as co-sponsors of legislation that would create a single payment system in New York. And Democratic Governor Andrew Cuomo is an ardent supporter of the ACA.

The state has been fully on board with the ACA implementation from the start, opting for a state-run exchange (NY State of Health) and expanding Medicaid to cover residents with incomes of 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, extending very low-cost health insurance (the Essential Plan) to residents with incomes up to 200% of the poverty level.

Medicare coverage and enrollment in New York

Medicare covers people over the age of 65, some people with disabilities, and people with end-stage kidney disease (ESRD). Eligible people can sign up for "original" Medicare or Medicare Advantage. Under original or "traditional" Medicare, the federal government pays directly for the health service you receive. In Medicare Advantage, you've chosen from one of the many private health plans in your state, and the federal government pays for the health care plan you receive. Medicare Advantage is required to provide all services covered by the original Medicare, and individual plans may offer optional additional services within the premium you pay.

Medicare enrollment in New York reached nearly 3.7 million enrollees in 2020.

New York Health Insurance Resources

● Community Health Advocates