Immigrants Need Clarity on Public Charge

New York’s 2021-2022 budget includes some important provisions that will help patients access affordable health care. But the state could have done so much more given its 31 percent increase in tax revenue and budget surplus.

Successful coverage expansions that were advocated for by HCFANY include:

  • Essential Plan: The budget increases the eligibility limit for the Essential Plan from 200% to 250% of the federal poverty level (about $34,000 a year for one person).  The popular Essential Plan currently covers over 900,000 people with no premiums or deductibles. The eligibility increase will mean an estimated 14,000 uninsured New Yorkers will get health insurance, and another 92,000 will have lower cost health care.
  • Medicaid for people over 65 and those with disabilities:  People over 65 and who have disabilities have only been eligible for Medicaid if their incomes are below 84% of the federal poverty level (FPL), even everyone else can quality with incomes up to  138% of FPL (around $18,700 for an individual). They have also faced an asset test, which is not required for everyone else.  The budget increases their eligibility limit to 138% of the federal poverty level to match that of other New Yorkers. It leaves the asset test in place, but increases the value of allowable assets.
  • Medicare Savings Program: The budget also increases the income limit for the Medicare Savings Program from 135% of the federal poverty level to 186% ($25,277 for one person). This means more people will get help paying for their Medicare Part B premiums (currently $170 a month) and paying for prescription drugs. 
  • Post-pregnancy Medicaid: The budget extends post-pregnancy Medicaid coverage to one full year from 60 days for all New Yorkers, regardless of immigration status.

The budget includes other changes that improve the health care system for New Yorkers:

  • The Child Health Plus program will no longer have premiums for households earning below 223% of the federal poverty level (about $62,000 a year for a household of 4). These premiums were associated with the annual loss of health coverage for nearly 70,000 children.  Benefits for Child Health Plus were also improved to cover mental health and orthodontia.
  • The budget increases funding for the Community Health Advocates (to $5.2 million) and the Community Health Access to Addiction and Mental Healthcare Project programs (to $3 million). These programs provide post enrollment assistance, such as helping people appeal insurance denials, medical billing problems or locating in-network care.

Immigrant Coverage

The budget expands Medicaid coverage to all New Yorkers over 65 regardless of immigration status. While the budget did not include HCFANY’s #1 priority, Coverage 4 All, the expansion for older adults is a first step that moves New York closer to states that lead on immigrant coverage, such as California. The budget also includes everyone in the post-pregnancy Medicaid coverage regardless of immigration status, a change from the Governor’s original proposal which excluded some immigrants.

No one should be excluded from health coverage because of their immigration status. The #Coverage4All bill (A880A/S1572A) would have created a health insurance option for low-income immigrants who would be eligible for the Essential Plan just like other low-income New Yorkers but for their immigration status. HCFANY will continue to advocate for the enactment of the Coverage4All stand-alone bill and stands ready to work with the Hochul Administration to secure federal funds for immigrant coverage.

What’s Next

The state legislature is in session until June 2. New York has a lot to do before then! Priorities for health care include:

  • A6058/S5474, the New York Health Act, would create a universal single-payer health care system in New York. It would eliminate barriers to eligibility based on immigration and income. It would also eliminate the medical billing chaos that causes so much grief for so many New Yorkers.
  • A7363A/S6522A would ban medical providers from placing liens on patients’ homes or garnishing their wages to recoup a medical debt judgment. This bill has already passed the Assembly – now we just need to get it through the Senate! Other medical debt bills include A8441A/S6522A, which reforms the hospital financial assistance law so patients can avoid debt, and A3470C/S2521C that would ban facility fees for preventive care and provide for better disclosure. 
  • A6883/S5954 would use $300 million from the state’s indigent care pool to increase Medicaid rates for Enhanced Safety Net Hospitals and qualified safety net hospitals.
  • A2251A/S3131A would require public notice and a public hearing in advance of a planned hospital closure. 

2021 was a difficult year for New York patients. As the COVID-19 pandemic continued to overwhelm people and systems, patients still faced astonishingly high medical bills and issues getting coverage – putting their finances and well-being at risk during a global crisis. As a result, 2021 saw a major surge in patients avoiding necessary medical care due to cost.

Despite the challenges, advocates scored a number of important policy wins that bring New York closer to achieving health care for all. Those wins include:

  • At least five different hospital systems have changed their debt collection policies, savings thousands of patients from lawsuits and property liens.
  • Both NY houses passed the Fair Consumer Judgment Interest Rate bill, which would cut the medical debt interest rate from 9 to 2 percent.
  • Governor Kathy Hochul signed the Health Equity Assessment bill into law, requiring hospitals and other health facilities to consider the impact on marginalized groups when making sales and closures.

These changes will have a significant impact on access to and affordability of care in New York, but we’re just getting started. Let’s make 2022 the best year for NY patients yet, by fighting to end medical debt once and for all, getting everyone covered regardless of immigration status and passing the New York Health Act to ensure everyone can access the care they need.

A state Workgroup investigating ways to simplify administrative processes around health care recommended a number of policy changes that could make life easier for patients. The Health Care Administrative Simplification Workgroup was created in the FY20-21 enacted budget and submitted its final report to the Legislature a few weeks ago.

Several of the Workgroup’s recommendations had been proposed through last year’s Patient Medical Debt Protection Act, which would have enacted significant financial protections for patients – but did not pass the state Legislature. Key recommendations from the Workgroup include:

  1. Standardizing the Financial Assistance Application: The Workgroup recommended that the state develop a standardized form to be used at all hospitals for financial assistance applications. New York State started auditing hospitals’ compliance with the hospital financial assistance law in 2012. Hospitals routinely fail this audit by requiring information Social Security numbers, and tax returns as part of the application. This leads to low- and moderate-income patients becoming responsible for bills that the state has already determined they cannot afford. A standard application would eliminate these hurdles.
  2. Regulating Facility Fees: Another piece of the Patient Medical Debt Protection Act that appears in the Workgroup recommendations is that providers inform patients about facility fees before they receive services. The Workgroup also recommends prohibiting facility fees charges for preventive care visits. Facility fees are overhead charges for hospital care, but they are increasingly charged to patients who receive services elsewhere as more and more doctors’ offices are purchased by hospitals. This recommendation could be enacted this year by passing A3470B/S2521B.
  3. Standardizing Financial Liability Forms: Another patient-friendly recommendation from the Workgroup is for providers to standardize patient financial liability forms. Patients are sometimes asked to sign these forms before appointments without adequate time to understand what they are signing. This is an unfair practice, as the forms ask patients to accept financial responsibility for the costs of care before they know what care they need or how much it costs. Patients have even been denied care for refusing to sign the forms.

           Another batch of recommendations in the report would improve the prior authorization process, which is how health plans decide whether a doctor’s recommendation is medically necessary before approving payment. The Workgroup recommended that plans clearly identify which services require pre-authorization, review those services annually to decide if pre-authorization is sensible, and flag situations where patients are required to get multiple pre-authorizations for the same treatment when it is needed more than once. The Workgroup also recommends that health plans post their clinical review process in an easily accessible location on their websites so that patients and anyone helping them can understand why services are authorized or not. Patients need this information to appeal decisions that might be against medical best practices or are inappropriate for their specific health care needs.

The Biden Administration is planning to draft a new public charge rule, and is gathering information before it does so through a public comment process. Advocates have until October 22 to submit their comments (you can read the request for comments here.)

The previous Administration’s expansion of the public charge rule is still harming New Yorkers. The Trump Administration proposed a major expansion of public charge in September 2018. The proposal, if enacted in full, would have meant immigrants who used a long list of public programs could later be denied permanent residency. The final rule was much smaller in scope than what was originally proposed, and did not include health programs like Medicaid.

Further, the final rule was revoked by President Biden in March 2021. But the proposal caused damage in-and-of itself: immigrants who were not subject to the rule still fear enrolling in programs that will help them access health care, even when those programs were not part of the expanded public charge rule. This confusion and fear surrounding the rule is known as the “chilling effect.” Immigrants were afraid to make mistakes that would jeopardize their future here while the rule was in place, and they are still afraid that a future Administration will use their health care needs against them. As many as 260,000 low-income children lost access to desperately needed health care and other services during 2020 because of the chilling effect.

President Biden must address these fears by clearly defining public charge in regulations. Public charge was applied narrowly before the Trump Administration, so narrowly it was almost never used. The new rule should explicitly and narrowly define public charge to avoid future abuses. It should also explicitly list programs that are not subject to public charge, like Medicaid and SNAP. Protecting Immigrant Families has created a sign-on letter for advocates with other recommendations; the deadline to sign on is October 20. Advocates who sign the joint letter should also consider submitting their own individual comments. Another good resource is this Health Affairs blog post.

New York State and the Biden Administration also need to do more to make sure immigrants can access health care:

  • Some New Yorkers are barred from enrolling in public health coverage because of their status. New York could immediately provide relief to those excluded immigrants by passing A880/S1572, which would allow income-eligible immigrants to enroll in the Essential Plan. 
  • At the federal level, the Biden Administration should remove the 5-year bar to becoming eligible for Medicaid coverage.