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New York’s Family Health Plus Insurance Expansion Presentation by Rima Cohen Vice President, Insurance Options Greater New York Hospital Association March 1, 2000
New York State’s Demographics • 18 million people • Approximately 2 million immigrants • 3 million uninsured
Sources of Health Insurance Coverage, Non-Elderly Population Source: March 1997 Current Population Survey. Percent of non-elderly population
New York’s Growing Uninsured Problem New York’s uninsured population is larger and growing faster than in the rest of the country Source: United Hospital Fund, 1998. Percent of nonelderly population
Who are New York’s uninsured? • New York’s 3.1 million uninsured are mostly low-income working adults without access to employer-based coverage, as in the rest of the country. • Roughly one-third of New York’s uninsured are immigrants.
Proportion of Uninsured:Adults vs. Children 75% of New York’s non-elderly uninsured are adults (ages 19 to 64) and 25% are children (under age 19).
Over two-thirds of NY’s uninsured are below 200% of the federal poverty level (FPL). Source: United Hospital Fund, 1998.
Nearly three-fourths of NY’s uninsured are in the workforce. Source: United Hospital Fund, 1998.
Private coverage in NY is declining faster than in the nation as a whole. 1991 1996 Source: United Hospital Fund, 1998. Percent of nonelderly population
New York’s Medicaid Program • 2.7 M enrolled; $ 22.5 B per year; 50% Federal matching rate + 25% State + 25% Counties • Single/childless adults covered under New York’s 1115 waiver up to 53% of poverty • Enrollment declining, especially among non-elderly adults and individuals receiving cash assistance • 3.12 M in 1995 to 2.74 M in 1999 • Mandatory Medicaid managed care is being phased in • Enrollment process fairly complicated • Requires face-to-face interview • Asset test • 8-page application
New York’s Child Health Plus (CHP) Program • Provides comprehensive insurance, with nominal or no premiums, to children (through age 18) under 250% poverty level who are not eligible for Medicaid • Relatively simple application and enrollment process • Covers 435,000 children with 10-20,000 new children enrolling every month; however, many disenroll while they are still eligible • Costs: $450 M per year
HCRA 1996 • Funded many health programs, including Child Health Plus, graduate medical education, and charity care for health care providers • Expired December 1999 • NY Assembly passed HCRA reauthorization (HCRA 2000) in June 1999 • Includes Family Health Plus insurance expansion proposal developed by GNYHA and other groups
Diverse coalition supports Family Health Plus insurance expansion. • GNYHA (hospitals) and 1199 National Health and Human Service Workers Union launch multi-million dollar public education and advocacy campaign • TV & Radio ads • Direct mail • 800-line and phone banking • Free media • New York State Health Care Campaign (broad coalition that includes consumer advocates and public health groups) • Grassroots initiatives
HCRA 2000:Passed December 30, 1999 • $2.6 B per year for health care programs • Continued funding for graduate medical education and hospital charity care • Three new programs for expanding health coverage in New York • 55 cent per pack tobacco tax increase and tobacco settlement funds dedicated entirely to health care
HCRA: Insurance Initiatives • HCRA 2000 creates 3 new programs that will expand health coverage in New York: • Family Health Plus— Provides free health insurance to low-income, working adults; the largest of the 3 programs • Healthy New York (Small Business and Uninsured Workers Programs) — Allows uninsured small businesses and individual workers to buy subsidized insurance. • Direct Pay Fund— Creates a stop loss fund to soften premium increases in the individual market.
HCRA: Insurance Initiatives • When fully implemented, these initiatives will provide $900 million per year (including Federal matching funds) to make coverage available to up to 1 million New Yorkers. • State’s share of funding provided by proceeds from the 55 cents per pack tobacco increase.
What is Family Health Plus? Family Health Plus (FHP) is a new entitlement program, modeled on Child Health Plus (CHP), that offers comprehensive health insurance at no cost to low-income, uninsured adults.
Who qualifies for Family Health Plus? • Adults between the ages of 18 and 65 who are not eligible for Medicaid and • Have dependent children and earn up to 150% of the poverty level ($25,600 for a family of 4); or • Have no dependent children and earn up to 100% of poverty ($8,400 for an individual); and • Meet Medicaid’s definition of a “qualified immigrant” (e.g. most legal immigrants who arrived in the U.S. before 1996 or, if arrived after 1996, have lived in the U.S. for at least 5 years).
What benefits does Family Health Plus cover? • FHP provides comprehensive coverage (nearly identical to CHP) through managed care plans that contract with the State. • Benefits include hospital care, physician services, lab tests, x-rays, prescription drugs, DME, radiation therapy, ambulance and emergency room care, mental health & substance abuse care, and dental, hearing, and vision services (routine, preventive, and emergency). • Copayments are nominal.
New York needs HCFA approval for FHP Federal matching funds. • Parents will be covered under 1931(b) provision • Waiver needed to modify Medicaid benefits and include anti-crowd out provision • Single/childless adults will be covered under New York’s 1115 waiver • Amendment to 1115 waiver or a separate waiver needed to cover this population
How many people will Family Health Plus cover? When fully implemented, it is estimated FHP will be available to up to 600,000 adults.
How will people apply for Family Health Plus? FHP will have a more simple enrollment process than Medicaid: • Individuals can sign up through providers and an array of community-based organizations, as well as district social service agencies. Recertification is annual and can be done through a mail-in form. • Unlike Medicaid, FHP has no resource or asset test and CBOs and providers can conduct enrollment interviews. • FHP sets aside funds for an extensive outreach, marketing and enrollment assistance campaign.
Who pays for Family Health Plus? • When fully implemented, the total cost will be split among:
What is Healthy New York? Healthy NY is a new program that will offer small businesses and individual workers subsidized health insurance with limited benefits.
Who qualifies for Healthy New York? To participate, businesses must meet the following criteria: • No more than 50 employees; • No employer-based insurance for the past 12 months; • One-third of employees make less than $30,000 per year (or sole proprietor with a household income less than $35,500 per year); and • Employer must pay at least 50% of employee premiums. Individuals not part of a group plan must make less than $35,500 per year to qualify.
What benefits will Healthy New York cover? • Healthy NY policies will cover most basic health care services, but will not cover certain mandated benefits and will have much higher copayments than current small group policies. • For example: • Prescription drug coverage capped at $3,000 per year; • $500 copayment for inpatient care; • No coverage of • Inpatient mental health/substance abuse; • Home health care; • Chiropractic care.
How are Healthy New Yorkpolicies subsidized? The State will reimburse plans for 90% of claims paid between $30,000 and $100,000 per member per calendar year.
Direct Pay Stop Loss Fund • To temper premium increases in the direct pay market, the State will create a “stop loss” fund that will reimburse direct pay policies for claims between $20,000 and $100,000 per member per year. • Stop loss payments, which will total $40 million per year by 2003, will be split equally between HMO and point of service plans.