Making Sense of Delivery System Reform

The Affordable Care Act made a lot of changes – and improvements – to health insurance. But it was also meant to encourage changes in how health care is delivered – the care you get at the hospital, doctor’s office, pharmacy, and other places where people get health care.

Many people have frustrating experiences with health care that go beyond how it’s paid for. Maybe you can’t make an appointment without skipping work, or can’t get your prescription filled on time because of communication problems and end up skipping doses. Maybe you had to get a test done twice because re-doing it was easier than transferring your records to a new physician. Delivery system reform is meant to make the experience of getting health care better – in an ideal world, there would be seamless delivery system that lets doctors and patients focus on their health, not logistics.

HCFANY has produced a new issue brief to help consumers understand what is happening. Delivery system reform could be a great thing for everyone, but changing systems is always hard. A lot of stakeholders have learned to succeed under the status quo, and are afraid of changing how they do business. Consumers need to educate themselves about how delivery reform can benefit them and use their knowledge to encourage reform that benefits patients.

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Guest blog by Bob Cohen, Esq. Policy Director at Citizen Action of New York and Public Policy and Education Fund of New York.

Fall is almost here, which means it’s time to start thinking about open enrollment! For the fourth consecutive year, HCFANY is teaming up with the Health Education Project of NY (HEPNY) and other groups to hold outreach and enrollment summits throughout New York State. This year, we’ll also be focusing on post-enrollment challenges. We encourage navigators, certified application counselors, health advocates, community members, health providers, union members, health insurance plan representatives, and small business representatives to attend.

Over 2.5 million New Yorkers filed applied for health coverage with NY State of Health last year — a great success!

This is a great opportunity to focus on continuing issues. First, there are still many “hard-to-reach” individuals that still have not enrolled in health coverage because of issues like language barriers and lack of information even if they qualify for free or low-cost coverage through Medicaid or the Essential Plan. Second, some people are unfamiliar with many elements of how health coverage works, like deductibles and co-pays and navigating their plan’s network. Other individuals do not know what to do if they experience a problem, like medical bills that seem incorrect.

Each summit will feature a presentation on the state of outreach and enrollment by a NY State of Health representative, followed by speakers from Community Health Advocates (CHA) about how they can help consumers with post-enrollment issues, and finally presentations by the Health Care Education Project and Lois Uttley, Director of Raising Women’s Voices-New York, on health literacy. The first summit will be held on Wednesday, September 28 at the 1199SEIU in Albany from 11:00 AM to 2:00 PM. Please see the Statewide Flyer for the complete schedule of outreach and enrollment summits.

Yay BlogOnce again New York is leading the nation as one of only two states to implement a Basic Health Plan (BHP). As of January 31, 379,599 New Yorkers enrolled in comprehensive, affordable coverage through the New York’s BHP, branded the Essential Plan, which launched in 2016. A few weeks ago, the NY State of Health (NYSOH) released its report on the third open enrollment period, which ran from November 1, 2015 through January 31, 2016. HCFANY is excited to see so many consumers gaining access to health care through the EP in its first year.

The EP is meeting an important need for consumers in New York, particularly for those with incomes between 138 and 200 of the Federal Poverty Level (FPL). Before the implementation of the Essential Plan, individuals at this income level would only have been eligible to purchase Qualified Health Plans (QHP) with financial assistance, and many continued to face financial barriers to coverage. With the EP, low- and moderate income individuals can now receive coverage comparable to that of a QHP for a premium of $0 or $20 and no annual deductible. The average consumer saves over $1,100 compared to QHP coverage. This increased affordability has resulted in high enrollment levels for EP eligible individuals. According to NYSOH’s open enrollment report, 98 percent of individuals determined to be eligible for the Essential Plan enrolled compared to only 58 percent of individuals eligible for QHP.

Essential Plan coverage is also available to individuals under age 65 with incomes below 138 percent of the Federal Poverty Level (FPL) who are lawfully present in the United States, but have not met the five-year bar to qualify for Medicaid as well as lawfully present immigrants with incomes 138 to 200 percent of FPL.

Like Medicaid and Child Health Plus, individuals and families eligible for the EP can enroll throughout the year.

To enroll or learn more about the Essential Plan, contact NYSOH at (855)-355-5777 or can also get free one-on-one help from a Navigator or Certified Application Counselor, certified by NY State of Health, who serves your area at Or contact Community Health Advocates at (888)-614-5400 or

CID-NYGuest blog by Heidi Siegfried, Project Director at New Yorkers for Accessible Health Coverage (NYFAHC) and Health Policy Director, Center for Independence of the Disabled. A few days ago, Health Affairs published an article that highlighted how the non-discrimination provisions of the Affordable Care Act (ACA), Section 1557, can protect consumers against benefit designs that discriminate against people with chronic conditions or significant health needs.

New York has long prohibited denial of coverage or premium variation based on health status and the ACA now prohibits charging higher premiums or denying coverage for people with pre-existing conditions. Still, network and formulary designs can have the effect of discriminating against people with serious illnesses and disabilities.

People often overlook the fact that Section 1557 prohibits discrimination based on disability status as well as race, color, national origin, sex, and age.  HCFANY and NYFAHC submitted comments to the U.S. Department of Health and Human Services (HHS) on the proposed rules for Section 1557 in November 2015. In these comments, we asked HHS to specifically define discriminatory benefit design in the regulations implementing Section 1557 and to include all beneficiaries with chronic conditions or serious illnesses.  Although HHS did not provide a definition, they do consider benefit design discrimination on a case-by-case basis and will review complaints of disability-based discrimination. HHS also provides examples of potentially discriminatory benefit designs such as placing all HIV drugs on the highest tier.

The Health Affairs article points out that the Americans with Disabilities Act was amended to define disability as an impairment of major bodily functions such as immune system, normal cell growth, digestive, bladder, neurological, respiratory, and endocrine systems which would reach many people with chronic conditions.  Therefore, when consumers encounter discriminatory formularies, coverage limitations, or plans that exclude certain specialists, they can use Section 1557 to enforce their rights to non-discriminatory benefit design by filing complaints with the Office of Civil Rights at HHS or by challenging the plans in court.