Health Care a Big Winner in 2014-2015 NYS Budget


Last week, the final NYS budget agreement was released. You can read HCFANY’s response in our press release, here. The budget contains major wins for health care consumers in New York, including all three of HCFANY’s top budget priorities: The Basic Health Program, out-of-network surprise billing protections, and consumer assistance funding.

1. Making health insurance more affordable for low- to moderate-income New Yorkers through the Basic Health Program.

The budget includes authorizing legislation to create a new Basic Health Program (BHP), which will provide low-cost insurance coverage to people just above the Medicaid level up to 200% of the Federal Poverty Level (approximately $23,000 for an individual, $42,000 for a family of four). Those in the higher income levels (between 150 and 200% of FPL) would pay a monthly premium of up to $20. The BHP will help thousands of New Yorkers with incomes too high to qualify for Medicaid but who struggle to afford private insurance even with the financial assistance now available through NY State of Health. It will likely be available starting in 2016. You can read more about the Basic Health Program in our policy brief and recent blog posts from Georgetown Center for Children and Families and Families USA.

2. Expanding consumer rights and protections for those who need and/or receive out-of-network services.

The budget also includes landmark legislation that will protect New Yorkers from out-of-network surprise bills, and will offer expanded rights for consumers, such as the right to go out-of-network when their plan doesn’t have a qualified in-network provider who can meet their needs. HCFANY has been advocating for these protections for several years. The new legislation includes:

  • Protection from “surprise medical bills” for emergency services and for scheduled services when an in-network provider is not available or the consumer is not informed in advance that out-of-network providers will be involved in providing care. Consumers will be held harmless (responsible only for the in-network copays and other cost-sharing), and it will now be up to insurers and providers to resolve billing disputes with the help of an independent arbiter.
  • The right to go out-of-network at the in-network rate, either for services that an insurer’s network doesn’t provide, or when an insurer’s network does not have an appropriate provider in-network. Out-of-network referrals must be made by in-network providers. An independent, external review process can be used when needed.
  • Improved network adequacy. All health care plans will now have to meet the same level of network adequacy standards, whether they are HMOs, PPOs, EPOs, or other types. Insurers that do offer out-of-network coverage will have to market at least one plan that provides it at a decent, fairly robust level.
  • Improved disclosure of information. Insurers must keep their network lists up-to-date (within 30 days), and disclose at what rate they reimburse for out-of-network services (when they are covered). Providers must keep their list plans they take up to date (within 30 days) and disclose how much they charge for a given service when provided out-of-network.
  • New options to  submit claims. Consumers must be allowed to submit out-of-network coverage requests and claims electronically.

3. Continued funding for community-based health consumer assistance services across the state. 

Additionally, the budget authorizes $2.5 million in pass through federal funding for Community Health Advocates (CHA), the State’s designated consumer assistance program. CHA helps consumers use their health coverage, access health care services even if they don’t have coverage, and understand how to resolve disputes with health insurers. Now that hundreds of thousands of New Yorkers have gotten health insurance through the “New York State of Health” marketplace, these services are needed more than ever. You can read more about CHA in our recent blog post.

In addition to these important advances, the budget includes continued funding for NY State of Health, the official health plan marketplace. As of April 7, over 908,000 New Yorkers have enrolled in affordable, quality health coverage through the marketplace. Approximately 70% of enrollees were formerly uninsured, and about half qualified for Medicaid or Child Health Plus, while the rest enrolled in one of the new Qualified Health Plans. The State is well on its way to meeting or even exceeding it’s goal of 1.1 million New Yorkers enrolled by the end of 2016.


Jessica K., 27, enrolled in health insurance through NY State of Health in February
with the help of a Navigator from Community Service Society

As strange as it seems, the 1st open enrollment period under the ACA has come to an end. The final count of enrollees from NY State of Health is stunning: more than 865,000 New Yorkers enrolled in private and public plans between October 1 and April 1. While some New Yorkers will not have the opportunity to enroll in NY State of Health Coverage until the next open enrollment period on November 15 of this year, hundreds of thousands will still be able to enroll in private and public health insurance plans in the coming months.

This is due to a series of extensions and special enrollment periods, as well as different enrollment rules for public programs such as Medicaid and CHIP. A short guide to these post-open-enrollment opportunities is below.

New Yorkers who are unable to enroll in NY State of Health due to technical glitches will be allowed to complete their applications after March 31.

The Obama administration announced Tuesday, March 25 that individuals who have started their applications before the March 31 deadline but were not able to complete the process before the deadline will have more time to enroll. Shortly after, New York agreed to do the same for those who had made a “good faith” effort to complete their application. These New Yorkers will have until April 15 to finish up.

Domestic violence victims will have until May 31 to apply.

A little known provision in the ACA prevents married couples who file separately from being eligible for premium subsidies. This causes problems for individuals with a barrier to filing for divorce or legal separation, such as domestic violence victims. Last week, the Treasury department announced it would issue guidance that married individuals living apart from their spouse and unable to file a joint return as a result of domestic abuse, will be able to file separately from their spouse and still claim a subsidy. Domestic violence victims will have an extension through May 31 to apply.

New Yorkers may qualify for a special enrollment period to enroll after the deadline.

As with any insurance, there are special circumstances that qualify people to enroll in NY State of Health after the open enrollment deadline has passed. These circumstances are called “qualifying life events,” and they include:

  • Getting married
  • Having, adopting, or placement of a child
  • Permanently moving to a new area that offers different health plan options
  • Losing other health coverage (e.g. due to a job loss, divorce, loss of eligibility for Medicaid/CHIP, expiration of COBRA coverage, a health plan being decertified, aging out of the ACA provision allowing young adults to stay on their parents’ insurance until age 26)
  • For those enrolled in Marketplace coverage, having a change in income or household status that affects eligibility for tax credits or cost-sharing reductions.

There are also more complex cases, which you can learn about here.

New Yorkers eligible for Medicaid and Child Health Plus (CHP) can enroll at anytime of the year.

New York’s Medicaid and CHP programs operate under a policy called “continuous enrollment,” meaning people can enroll at anytime of the year. You can learn more about New York’s Medicaid program here and the CHP program here.

So, while open enrollment has ended, there are still plenty of opportunities for New Yorkers to apply for affordable health coverage through NY State of Health.

speakout pic Mark H speakout pic Heidi

HCFANY steering committee members Mark Hannay of Metro New York Health Care for All Campaign and Heidi Sigfried of New Yorkers for Accessible Health Coverage “speak-out” to stop surprise medical bills by sharing consumer stories

Yesterday, HCFANY members joined advocates from Medicaid Matters New York and New Yorkers for Accessible Health Coverage to make a final push for the Basic Health Program, consumer protections from out-of-network surprise medical bills, and much needed consumer assistance program funding. New York’s budget process is set to wrap up in sometime in the coming week, with the goal of a final budget by April 1.

Advocates met with several legislators and staff, emphasizing the importance of creating the Basic Health Program and supporting health consumer assistance, in addition to other issues.

Basic Health Program

The Basic Health Program would have clear benefits for consumers, offering more affordable health insurance to New Yorkers who earn too much to qualify for Medicaid but not enough to afford in insurance through NY State of Health, even with subsidies. Initial reports from the Urban Institute and Community Service Society also projected State savings if the program were implemented, which makes sense given that the program would be largely funded with federal dollars.

Even so, the program was not included in the Senate’s budget proposal and negotiations continue. An updated Urban Institute analysis of the program’s projected fiscal impact is due to be released any day now, but the legislature could pass the bill without this report – the bill includes language that says the State doesn’t have to create the program if it turns out the cost would be too high. Advocates continue to educate legislators about the importance of this program for the health of our residents, as well as the State’s financial health. You can learn more about how to take action for a Basic Health Program on our website.

Consumer Assistance Funding

Also missing from the Senate’s budget proposal is a pass-through of funding for Community Health Advocates (CHA), the state’s consumer assistance program. The proposed funding for the program, which helps New Yorkers use their health insurance once they have it, is entirely from federal sources. Given the past successes of the program – CHA has saved over $12 million for New Yorkers over the past four years – and the fact that no state money would be involved, it is unclear why the program was removed from the budget.

Out-of-Network Protections

The day also involved several activities related to surprise medical bill protections that are currently in the Governor’s, Assembly’s and Senate’s budget proposals, but are yet to be fully resolved. You can read more about the current state of out-of-network negotiations here.

In the morning, partners held a press conference featuring various advocates from HCFANY, New Yorkers for Accessible Health Coverage, American Cancer Society Cancer Action Network, Consumers Union, AARP, and New York Public Interest Research Group. Superintendent Benjamin Lawsky shared his perspective on the importance of protecting consumers from surprise medical bills, an issue he and his staff have championed for several years (See Sup. Lawsky’s report, “An Unwelcome Surprise,” for more).

Consumer Claudia Knafo shared her personal story of surprise medical bills – nearly $100,000 worth – that she received in 2012 after spinal surgery from a doctor she had every reason to believe was in-network. Claudia did extensive research before booking the surgery, and she still got stuck with the bill – it turned out the surgeon, despite his website listings and numerous assurances from staff and her insurance plan, had not been a part of the plan since 1997.

Later in the afternoon, Claudia joined other advocates to hold a “consumer speak-out” to stop surprise medical bills in front of the Assembly Chamber, followed by the Senate Chamber. Participants read dozens of stories from consumers across the state who have faced surprise medical bills for out-of-network services they didn’t know they were receiving. From emergency surgeries to deliveries, these consumer stories represent just a small fraction of New Yorkers who desperately need stronger consumer protections in this area.

Learn how to take action to stop surprise medical bills here.


It’s been a busy week where the New York State budget is concerned, as the Assembly and Senate worked hard to release their respective budget proposals. We’ve been monitoring this process closely to see if HCFANY’s budget priorities – Basic Health Program, out-of-network billing protections, and funding for consumer assistance – made the safe transition from the Governor’s budget to the house proposals. Both proposals have now been released, and you can get HCFANY’s take on the house budget proposals below and in our recent press releases on the Assembly and the Senate proposals.

The Assembly’s Proposal

Released on Wednesday morning, the Assembly’s budget proposal includes all three of HCFANY’s budget priorities. The Assembly accepted all aspects of the Governor’s proposal to create a Basic Health Program (BHP). The BHP has the potential to benefit New Yorkers and the State’s coffers: it would make health care more affordable for thousands of lower-income working New Yorkers, while also bringing in federal funding to save the State in the hundreds of millions of dollars.

The budget proposal also includes several consumer protections related to out-of-network health care services, even improving on the Governor’s original proposal by requiring that all plans offer an option for out-of-network coverage. Like the Governor’s proposal, the Assembly’s proposal would protect consumers who receive “surprise” medical bills for out-of-network services they didn’t even know they were receiving (e.g. during an emergency room visit). Consumers would be taken out of the billing negotiations for these services, leaving it up to the provider and the plan, with the help of an independent entity, to decide an appropriate fee and payment. Consumers would just need to pay their regular co-pay and any other cost-sharing associated with visits to in-network providers. The budget proposal also requires all plans to adhere to network adequacy requirements, which currently only apply to HMOs in New York State.

Finally, the Assembly included what amounts to $2.5 million in federal funding to help consumers use their health insurance, by funding the state’s designated consumer assistance program, Community Health Advocates.

The Senate’s Proposal

The Senate’s budget proposal was a little slower to come, reportedly due to disagreement on certain issues. A resolution was finally released yesterday evening and results, at least in terms of affordable, quality health care, are more mixed.

Out-of-network protections were included, showing that all three entities are moving towards addressing out-of-network billing problems and network adequacy limitations in this legislative session. The Senate’s proposal largely mirrors the Governor’s and Assembly’s proposals, with a few technical differences. Importantly, there is no clear requirement that plans offer an out-of-network option, though the Senate did express their concern about availability of this coverage for consumers and may address the issue as negotiations move forward.

The Basic Health Program is also mentioned, though the Senate has not yet made a final decision as to its inclusion. Instead, the Senate proposes to wait until a complete analysis of the financial impact of the program is available, which is set to be released any day now. Community Services Society and the Urban Institute have both analyzed the financial impact of BHP in the past, finding that it could save the State hundreds of millions of dollars due to the federal funding available. It’s encouraging that the Senate chose to mention the program and has committed to a deeper analysis once the financial results are available.

There were also a couple of unwelcome surprises in the Senate’s proposal. Namely, the Senate proposes to defund the NY State of Health and neglects to authorize the federal funding for consumer assistance. Both actions are puzzling, as these programs have significant benefits, low or no cost to the State and they involve significant federal funds flowing into New York State. Six hundred thousand New Yorkers have already found affordable health insurance on the NY State of Health, and many more are likely to do so before the open enrollment period ends on March 31. And, thousands of New Yorkers each year benefit from the State’s designated consumer assistance program, Community Health Advocates, which helps people use their insurance and deal with problems, such as billing issues.

Both houses will now launch into final negotiations, with the final process scheduled to wrap up by the end of the month.

Is this all sounding like a foreign language? In case you’re unfamiliar with New York’s budget process, which is surely not intuitive, here’s how it works (in brief):

First, the Governor releases his proposal, called the Executive Budget. This year, the Executive budget was released on January 21, and you can read our analysis of some of the health care pieces on our blog. The Assembly and Senate spend a few weeks considering the Governor’s proposals before releasing their own budget proposals, called the “one-house” bills. After the release of the “one-house” bills, the houses break into “conference committees” to deal with final negotiations around various aspects of the budget, before the final “enacted budget” is passed. This is the law that governs how the State spends its money and runs its programs. The whole process is scheduled to be complete in two short weeks, by the end of March.