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.

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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.