Transgender people across the country face discrimination and other barriers to care which can make it difficult to achieve their health care goals. These barriers are there for New Yorkers, too, and came up during a HCFANY-led focus group looking into how LGBTQ+ New Yorkers are affected by medical debt.  Participants described high medical bills after coverage denials for gender-affirming care – despite plans covering these same procedures, like hormone therapy, for cis patients. The discussion also found that LGBTQ+ New Yorkers are still paying out-of-pocket for surprise bills, even as they should be protected under New York’s Surprise Bill Law.

LGBTQ+ New Yorkers should know that they can get support from the State and from advocates if they experience discrimination in the health care system. New York State requires coverage for all gender-affirming treatment and last year required NYS-regulated insurance carriers to develop evidence-based medical necessity criteria for gender-affirming care. All plans are required to submit their criteria to the State for approval and in June the State announced that carriers are complying with the requirements. This is important because it means medical necessity decisions are more standardized and if anything goes wrong, plan members have documentation of what the plan was supposed to do. Until the State required it, many plans had no written policies on gender-affirming care. When they did, their policies didn’t always match medical best practices and categorized necessary treatments as cosmetic.

In its “Health Coverage Information for Transgender New Yorkers” guide, the state describes the process for appealing denials or filing complaints with the state when your rights have been violated. You can also get help from programs like the Community Health Advocates. They can help you no matter what type of insurance you have. Fighting to get health care you need can be exhausting and painful – if you want help, you don’t have to take on the entire burden by yourself.

CHA advocates can also help with the surprise bills that so many focus group participants described. These billing problems included bills that are clearly covered under New York’s Surprise Bill law and receiving multiple bills of varying amounts for one service. One participant received a medical bill that was so unclear she could not find contact information to pay it, even after multiple calls to the hospital where she received care. Another described conversations with their providers’ billing office as feeling “like a tennis ball being bounced around different courts.”  

New York should continue to monitor insurance policies on gender-affirming care and ensure that plans who violate coverage requirements are held accountable. It should also make sure that consumer assistance programs like CHA are fully funded so that patients have support dealing with unclear and unfair medical bills.

Medicare is a life-saver for older Americans, but it does have out-of-pocket costs that can expose some patients to medical debt. A new issue brief created for HCFANY by the Medicare Rights Center explains some of the causes of medical debt for people enrolled in Medicare and describes some steps patients can take to avoid it.

Some of the causes of medical debt for people covered through Medicare are the same as for people with other types of insurance. More and more New Yorkers say they cannot afford to pay for care because of deductibles and out-of-pocket costs. This can be especially difficult for patients who are cannot afford supplemental coverage but are not low-income enough for Medicaid.

Like other patients, people with Medicare deal with medical billing errors and service denials. Patients who have had their care plan denied by insurers are then in a position where they have to ask their doctor for a different care plan; attempt to appeal, which can be overwhelming without help; or pay on their own. Finally, Medicare patients have to navigate covered versus non-covered services. Long-term care, dental care, and even ambulances can leave them on the hook for large medical bills.

Patients with Medicare coverage should review their Medicare Summary Notice to know what bills may be coming and whether any services they’ve received in the past three months were not covered. They can get help with billing questions, appealing service denials, or finding affordable care by calling the Medicare Rights Center at 800-333-4114.

New York State should also do more to protect patients from medical debt. One reason that medical errors are so common and that it is so hard for patients to know what services are covered by what providers is because the current health care system is so fragmented. A single-payer system, like the one that would be created by the New York Health Act, would eliminate the complexity that causes so much distress for patients in today’s system.

New York should also take steps to make medical billing more fair in the current system:

• Funding consumer assistance programs,
• Capping interest rates on medical debt judgments,
• Barring providers from placing liens on patients’ homes or garnishing their wages,
• Banning facility fees, and
• Making the state’s hospital financial assistance policy easier to apply for.

More New Yorkers than ever turned to NYSOH for affordable health coverage at the beginning of 2020. The latest NY State of Health (NYSOH) report shows that 25 percent of New Yorkers (4.9 million) enrolled in health coverage through the NY State of Health during 2020’s Open Enrollment Period.[1] This represents a 150,000 increase over 2019. The report documents enrollment between November 1, 2019 and February 7, 2020. Enrollment through NYSOH has increased every year since it was created, an indication of the need New Yorkers have for health coverage.

Most New Yorkers who used NYSOH enrolled in public plans like Medicaid (3.4 million), Child Health Plus (452,000), and the Essential Plan (797,000). Medicaid and the Essential Plan cover New Yorkers who earn up to 250 percent of the federal poverty level. Child Health Plus covers New Yorkers under the age of 19 with subsidies for families at lower incomes. About 273,000 New Yorkers used NYSOH to purchase private health insurance (Qualified Health Plans or QHPs), 60 percent with financial assistance through premium subsidies. QHP enrollees continued to show a preference for lower-cost options, with Bronze and Silver plans (plans with lower premiums) being the most popular throughout the State. Increasing premium costs are likely the cause of this trend towards lower premium plans, but those lower premiums come with higher deductibles. Even insured New Yorkers report struggling to afford health care – the trend towards enrollment in plans with lower premiums but higher cost-sharing is an important one for advocates to monitor.[2]

Assistors continued to play a key role in the success of last year’s Open Enrollment period, with around 80 percent of last year’s enrollments being conducted by assistors. Navigators, who are trained and certified by the state, are available to provide assistance all across New York – you can find help in your own community by calling 888-614-5400.

NYSOH has proven itself resilient over the years, from the early days when it was unclear whether or not consumers would use it at all through the Trump era when federal policy changes hurt Marketplaces in other states. In the months after this report covers, NYSOH took steps to ensure that New Yorkers were able to keep enrolling in health coverage even as millions lost their jobs or experienced other disruptions during the pandemic. Preliminary data shows that between February 2020 and February 2021, an additional 885,000 New Yorkers used NYSOH to obtain health insurance, and now a record 5.8 million people are enrolled through NYSOH—nearly a third of the state’s entire population.[3] This was only possible because of the investments New York has made over the years towards building a strong, integrated Marketplace where consumers have lots of help available to make the best choices for themselves.

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[1] NY State of Health At A Glance 2020 Open Enrollment Report

[2] New Statewide Healthcare Affordability Survey | Community Service Society of New York (cssny.org)

[3] NYSOH Press Release: NY State of Health Announces Enrollment Surges, More than 5.8 Million New Yorkers Enrolled in Health Coverage

New York State’s budget included harmful changes to Medicaid – though many of those changes are delayed (see our joint statement with other Medicaid advocates here). The Medicaid cuts are going to be an on-going issue throughout the year. But outside the Medicaid budget, there were a few wins for consumers.

Full Funding for Consumer Assistance Programs

New York’s consumer assistance programs received full funding. These programs include the Community Health Advocates and the Community Health Access to Addiction and Mental Healthcare Program (CHAMP). Both programs provide free, independent help to make sure your health insurance works and that you can access care. Both are running full speed ahead despite social distancing – if you ever need help dealing with care denials or prior authorizations or even finding a doctor, give them a call! You can find more info about the Community Health Advocates here, and about CHAMP here.

Other good CHAMP news – the budget created a fund to make sure that people who need assistance getting mental healthcare or addiction help can get the services they need. The fund will be filled using fines against health plans that do not follow the rules about ensuring access to those services. New York has had parity laws for a long time that require plans to treat mental healthcare the same as other healthcare – the fund will help hold plans accountable while providing resources to people who need care.

Protecting Patients from Medical Debt

Two parts of the Patient Medical Debt Protection Act made it into the budget (learn more about medical debt in New York here). One reduces the statute of limitations for medical debt court cases from six years to three. After six years, most people don’t have the same insurance or the records they need to defend themselves against hospitals in court. The budget changes the law so that these cases must be filed sooner, giving defendants a better chance to defend themselves. The second change closes a loophole in the state’s surprise medical billing law – now emergency charges by either the hospital or individual providers will be covered by the law. That means fewer unanticipated and unfair bills.

Making Prescription Drugs More Affordable

There were two actions on prescription drugs in the final budget. First, the budget caps co-pays on insulin at $100 every 30 days. There’s a lot more the state could do on prescription drugs (see S6492/A8533) but this will be a big help to people with insurance who depend on insulin. The budget also creates a drug accountability board that will help the Commissioner of Health investigate prescription drug price gouging.

Fair Hospital Funding

Finally, the enacted budget ends the transition collar for the state’s indigent care pool. The transition collar was part of a system that short-changed safety net providers and rewarded hospitals that provide little or no financial assistance to patients. Advocates have worked for years to improve how indigent care pool funds are distributed – and won some improvements six years ago. When the funding formula changes happened, the state instituted a transition collar to slowly phase them in. But the transition was extended every year – until now. Without it, New York will finally fully implement the formula improvements and move closer to a fair system. You can learn more about the indigent care pool and its history here.