Consumer Assistance Programs Help New Yorkers Use Their Health Insurance Once They Have It

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Kevin Dwyer, client of Community Health Advocates

A couple of weeks ago, we posted about enrollment hitting half a million New Yorkers on NY State of Health. We’re now at over 700,000 New Yorkers according to this week’s press release, 70% of whom were previously uninsured. Nearly one quarter of enrollees are signing up for insurance with the help of an in-person assistor – either a Navigator, a certified application counselor, or a broker – according to the most recent data on how people enroll. This number is likely to grow as more people find out about these services.

In-person assistors, located across the state, are doing phenomenal work helping people to enroll in health insurance plans, but their services are limited to enrollment: What happens after a person enrolls in a plan? The health care system is notoriously difficult to navigate, and consumers will continue to have questions about how to use their new insurance. This will be especially true for the nearly 500,000 New Yorkers who were uninsured before signing up on NY State of Health. Where can these consumers turn when they have a question or run into a problem with their insurance?

Thankfully, New York already has a designated program for this kind of consumer assistance. The program is called Community Health Advocates (CHA), and it’s there to help consumers use their insurance, once they have it. CHA provides services through a toll-free helpline (888-614-5400) and a network of community-based organizations and small-business organizations throughout the state of New York. The CHA helpline number is listed on every Explanation of Benefits from every insurance company in the state. And, since it became the state’s designated consumer assistance program in 2010, CHA advocates have tackled over 162,000 cases like this one and saved consumers over $12 million in health care costs.

CHA services can make a life or death difference in people’s lives. They likely did for Kevin Dwyer (pictured above). When Kevin’s insurance plan denied his request for a new, promising drug for his cystic fibrosis, because it had not been FDA-approved for his particular genetic mutation, he contacted CHA. His case was particularly surprising – and frustrating – because his sister, who has the same disease, genetic mutation, physician, and health plan – had gotten approval using the same approval. With the help of CHA advocates, Kevin was able to get the treatment he desperately needed. In his words, “With CHA, you’ve got somebody.”

HCFANY is actively advocating for sustainable funding for these important services. They are desperately needed, particularly now with so many newly insured New Yorkers. This year’s Executive Budget from Governor Cuomo and the Assembly’s budget proposal both include funding for Community Health Advocates – authorizing a pass-through of $2.5 million of federal funds to go to the program. However, the Senate bill has not yet agreed to authorize the funding, which is surprising given the positive impacts of the program and the fact that there are no state funds involved. HCFANY members and other organizations continue to work to ensure that this vital resource is supported in the final budget, which is set to be enacted by April 1.

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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.

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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.

 

 

 

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Photo: Advocates and consumers at HCFANY’s press conference about how the Governor’s budget would make coverage more affordable, stop surprise bills, and support consumer assistance programs. From left: Gladys Puglla, consumer; Mark Scherzer, New Yorkers for Accessible Health Coverage; Elisabeth Benjamin, Community Service Society; Lara Kassel, Medicaid Matters New York; Bob Cohen, Citizen Action of New York; Oswil Liz, consumer; Kate Breslin, Schuyler Center for Analysis and Advocacy (podium)

It’s budget season, and our advocacy efforts are in full swing. Yesterday, HCFANY members and supporters gathered in Albany from across the state – some trekking 5 hours to get there – to advocate for our key budget priorities:

  • Create a Basic Health Program
  • Protect consumers from surprise medical bills
  • Support consumer assistance programs

We were not alone – the halls and elevators were full of other advocates who came to the capitol to make their case to the legislature. More importantly, we are not alone in our continued efforts to advocate for quality, affordable health care!

Over the past few weeks, HCFANY and allied groups and coalitions have joined forces to make sure that the three proposals above (all in Governor Cuomo’s executive budget) remain in the budget as the process moves forward. We’ve submitted memos of support and organizational sign-on letters on surprise bills and our three budget priorities, and gathered in Albany for advocacy days. We’ve also held two press conferences featuring the real stories of New Yorkers who would be helped by the Governor’s budget proposals. This collaboration helps to amplify our voices in Albany.

Key Budget Priorities Press Conference

We kicked off yesterday’s HCFANY advocacy day with a press conference featuring both advocates and consumers. Members of the HCFANY steering committee – Mark Scherzer of New Yorkers for Accessible Health Coverage, Elisabeth Benjamin from the Community Service Society of New York, and Kate Breslin of Schuyler Center for Analysis and Advocacy – joined Medicaid Matters New York Coalition Coordinator Lara Kassel to outline the benefits of the Basic Health Program, out-of-network protections, and consumer assistance programs. And, we heard from New Yorkers who have been directly affected by these issues:

Oswil Liz, 24, spoke about the challenge of affording health insurance, even with the subsidies available on the Marketplace. Thanks to the ACA, Oswil now has insurance, but with student loans and his wages working as a manager at McDonald’s, the premiums are still difficult for him to afford. A Basic Health Program would benefit Oswil and others in his situation.

Gladys Puglla, a single mother with three children told the stunning story of her experience with surprise medical bills. When Gladys had a stroke in 2012, she received services at two hospitals. Gladys has insurance, but she was unconscious when admitted to both hospitals and so couldn’t give her insurance information. After her treatment, she was hit with $138,000 in surprise medical bills for out-of-network services. Gladys makes $37,000 a year. Thankfully, Gladys was able to seek help from Make the Road New York, part of the Community Health Advocates statewide network of consumer assistance services. With their help, Gladys was able to reduce her bill and received a grant from the New York Times Neediest Cases fund to pay the difference. Many consumers do not have these resources, which is why HCFANY is working to stop surprise bills and support consumer assistance programs like those that helped Gladys.

Surprise Bills Press Conference

Late last week, Bill Ferris of AARP, Blair Horner of New York Public Interest Research Group (NYPIRG), and Chuck Bell of Consumers Union joined HCFANY members Heidi Siegfried of New Yorkers for Accessible Health Coverage, Mike Burgess of the American Cancer Society Cancer Action Network, and Gene Veigl and Aaron Ward of the MS Society at another press conference calling on the Legislature to pass the Governor’s legislation specifically to protect consumers from surprise medical bills.

Claudia Knafo, a concert pianist who received a surprise medical bill seeking $101,000 for neck surgery, for which her health plan offered to pay only $3,500, told her compelling story.  You can see coverage by the local nbc affiliate here.

Learn more about our budget priorities:

Basic Health Program: take a look at our policy brief and read the Community Service Society 2012 report

Stop Surprise Bills: Read our policy brief and visit our new take action: stop surprise bills page and Consumer Union’s new website: stopsurprisemedicalbills.org.

Consumer Assistance: Read our policy brief and visit communityhealthadvocates.org