Summary of New York Health Plan (NYHP)
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
Financing
- 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
Providers
- 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
Governance
- 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