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Summary of New York Health Plan (NYHP)

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Eligibility and Enrollment

  • Anyone whose primary place of residence is located in New York, regardless of immigration status 
  • No waiting period for enrollment
  • Newborns would be enrolled at birth
  • Colleges may buy NYHP for non-resident students
  • *Sale of private insurance duplicating NYHP benefits prohibited
  • NYHP would include all New Yorkers with the following coverage today:
  • Medicaid (including the Essential Health Plan)
  • Medicare
  • Child Health Plus
  • New York State Health Insurance Plan (State and Local Government employees)
  • All coverage purchased through the New York State of Health Marketplace
  • Commercial Insurance
  • HMOs
  • Self-funded (note: not directly addressed but assumed*)
  • Retirees (voluntary)

Covered Services

  • Provides comprehensive inpatient and outpatient health coverage (pharmaceuticals, dental, vision, rehabilitative, etc.)
  • Includes all benefits, rights and protections as prescribed under State Insurance law or covered for State employees and enrollees in Medicaid, Medicare, and Child Health Plus 
  • Long-term care services (e.g., home health care, nursing homes) 
  • Existing retiree coverage and Workers Compensation could be included based on plan developed by Board of Trustees

Cost Sharing/Spending Controls

  • No premiums, deductibles, co-pays or co-insurance
  •  No network restrictions
  •  No prior authorization or utilization review


  • Creates New York Health Trust Fund
  • Imposes unlimited, progressively graduated payroll tax (“premium”) on employers (80%), employees (20%) and self-employed (100%), similar to the Medicare tax
  • Also imposes an unlimited, progressively-graduated tax based on other taxable income, such as capital gains, interest and dividends
  • Amount of tax would be included in revenue plan as part of State Budget set by Governor annually to cover the cost of the NYHP
  • Would seek federal waivers to fold public programs and accompanying federal funds into NYHP (Medicaid, Medicare and Child Health Plus) and any other federal health-related programs and spending (subsidies, tax credits, public health funds etc.)
  • Out-of-state employers of New York residents can voluntarily pay employer share of tax or resident taxed as if self-employed.
  • Non-resident New York State employees and their employers can receive credit for coverage for any NYHP benefit, excluding employees’ out-of-pocket expenses.

Payment for Services

  • Providers paid in full by NYHP (no co-pays or other charges allowed)
  • State Department of Health (DOH) negotiates payment rates
  •  Administration of claims payment not clearly addressed, but likely handled or administered by State DOH
  • NYHP only pays providers if enrollee has Care Coordinator when the service is provided
  • NYHP pays fee-for-service until other methods developed
  • NYHP negotiates rates with providers, Care Coordinators and Health Care Organizations
  • Providers can collectively negotiate with NYHP
  • Payment must be “reasonable and reasonably related to the cost of efficiently providing care and assuring an adequate supply of health care service”
  • NYHP can include capital component for not-for-profit facilities (no capital for for-profits)
  • Can fund direct and indirect graduate medical education
  • Pharmacies paid pursuant to the preferred drug and clinical drug review program, using 340B program where applicable


  • All providers meeting NYHP standards can participate
  • NYHP can revoke or suspend participation for incompetency
  • Providers qualified to participate under Medicaid, Child Health Plus or Medicare deemed qualified to participate in NYHP
  • Providers can be removed or barred from the program if they have “exhibited a course of conduct which is either inconsistent with program standards and regulations or which exhibits an unwillingness to meet such standards and regulations.”

Plan Operations

  •  Enrollees can receive services from any participating provider, subject to care coordination, willingness/availability of the provider, and clinically appropriate circumstances
  • Enrollees required to choose Care Coordinators to ensure enrollee gets needed care and follow-up and “effective use of medically necessary services,” but not for prior authorization or “gatekeeping”
  • Care coordinators must meet standards and be approved by DOH. Can’t be limited for economic reasons. Can include primary care practitioners, gynecologists, chronic care specialists, and not-for-profit or government sponsored OMH licensed facilities, DOH licensed Article 28, Article 36, managed long term care plans, “health care organizations,” or any other approved not-for-profit or government entity. For-profit coordinators must meet not-for-profit standards
  • Approved Health Care Organizations assume responsibility for all or part of enrollee’s care. Can include not-for-profit and government Accountable Care Organizations and Taft-Hartley funds
  • Health Care Organizations optional for both enrollees and providers
  • Not-for-profit NYHP Assistors will help potential enrollees, Care Coordinators and providers enroll, dis-enroll and navigate the NYHP. Will also help choose Care Coordinator
  • If State fails to secure federal waivers, enrollees must furnish NYHP with all information needed to allow NYHP to apply for any federal benefits
  • NYHP must provide grants to not-for-profits to promote public, environmental and occupational health
  • NYHP must fund health systems agencies
  • NYHP must fund job-retraining


  • 40 member Board of Trustees will advise State DOH on establishment and operation of NYHP
  • Board develops plans for long term care, retirees and Workers Compensation
  • Board reviews and proposes amendments to NYHP regulations
  • Creates six Regional Advisory Councils to advise the Board, State DOH, Governor, and Legislature
  • Regional Advisory Councils must hold at least four public hearings annually and adopt community health improvement plans to promote health care access and quality in their regions
  • Board and Councils have specific membership composed of consumers, providers, local government, employers and labor
  • 15 member Temporary Implementation Commission until Board fully constituted
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