April 2020 HealthWatch New York’s “Other” Individual Market Needs an Update Peter Newell, Director, Health Insurance Project, United Hospital Fund President’s Note As in many organizations across New a more effective health care system York, normal work life at UHF came for New Yorkers. This HealthWatch to an uneasy end on March 13, 2020, report from our Health Insurance when we began remote work without Project provides an analysis of the fully knowing the depth of the crisis off-exchange individual market that awaited us. Since then, with a and suggests some common-sense number of completed projects in the improvements that could be made. One pipeline and much other ongoing work of the recommendations—eliminating put on hold, we have prioritized work the enrollment barriers that prevent related to COVID-19. This includes the undocumented immigrants (ineligible creation of a resource page that features to shop at the NY State of Health a UHF consumer guide for maintaining Marketplace) from buying coverage at or finding new health coverage during their own expense in the off-exchange the pandemic, resources for parents market—is a particularly timely and pediatricians, and a series of one during the current pandemic commentaries presenting views on the and statewide effort to get everyone impact of coronavirus from all parts of covered. the health care system. Please stay safe. Resuming normal work life may still be weeks or even months away, but —Tony Shih, MD, MPH UHF will continue to produce work President, United Hospital Fund consistent with our mission to build New York’s Affordable Care Act marketplace, In New York,3 this helped assuage health NY State of Health, capped its seventh plans’ fears that an unsuccessful launch of the annual open enrollment period with an state exchange would leave them without an announcement that nearly five million state outlet to sell products, it preserved an option residents had signed up for coverage in for those who found it more convenient 2020, including about 273,000 purchasers to purchase coverage directly from a plan, of qualified health plans in its individual and, importantly, it retained a market for market component, both high-water marks.1 individuals who were ineligible to purchase Enrollment occurring during the special through an exchange because of their coronavirus open enrollment period will immigration status. add to those totals. New York’s other source for individual coverage—the off-exchange ACA requirements, actions by New York market—has contributed to the overall regulators and policymakers, and market improvement of the individual market responses by insurers have all shaped the in New York, but membership has been coverage that is available off the exchange. declining of late. At the same time, a Trump State policymakers took steps to ensure that administration immigration regulation that individual products would be available for took effect on February 24, 2020, could purchase off the exchange by restructuring an lead noncitizens to drop public coverage existing law. Before 2014, health maintenance or seek commercial coverage. This issue organizations4 operating in New York were brief examines the off-exchange market required to issue two standardized individual and presents some options for a timely market products. In 2014, new legislation tune-up, with a focus on barriers that prevent enacted in New York required most health noncitizens from enrolling off-exchange, a maintenance organizations (or their affiliated grave concern during the current coronavirus companies) to offer individual products pandemic. meeting ACA standards for qualified health plans. Insurers that chose to participate in Background the NYSOH were required to also offer at least one product in each “metal category” New York policymakers and regulators made off the exchange as well.5 However, specially dozens of decisions when implementing the licensed health maintenance organizations ACA in 2014, including whether to create that focused on public programs were allowed a state exchange or rely on a federal one greater discretion on which markets to enter. instead. For states like New York that opted The ACA and New York rules also required to create their own exchange, a second health plans to offer child-only plans, with decision followed: whether the exchange premiums set at 41.2% of the premium for would be the only market for all individual single individual coverage. Finally, one of coverage, including public programs, or the oft-overlooked byproducts of the ACA whether commercial coverage would be is that dental, vision, and combined dental available to individuals “off-exchange.” vision coverage—through both dental-only Vermont and the District of Columbia2 made carriers and insurers offering comprehensive their exchanges the sole source for individual coverage—became widely available for the and small group coverage, allowing these first time both as part of comprehensive smaller states to aggregate the largest number coverage and on a stand-alone basis through of covered lives within their marketplaces. All the NYSOH and off it. other states establishing their own exchanges, however, opted to allow off-exchange markets. 2 HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET | U N IT ED H O S PITA L F U ND New York’s Off-Exchange its peak in 2014 (133,356 enrollees), 71,700 Individual Market in 2019 enrollees were covered under off-exchange individual policies in 2019,6 about 20% of Some health plans participate in the off- total individual enrollment. According to exchange market because they have a little one detailed analysis of product offerings more FIGURE leeway with1.benefit DISTRIBUTION design than with OF PLANS IN NEW YORK nationally (Figure 1), plenty of off-exchange RATING products REGION offered through 4, 2020 the NYSOH. By the same token, some consumers may be products were available in New York State attracted to off-exchange products, may in the rating region that includes New York prefer to purchase directly from a health City and some suburban counties. Figure 2 plan rather than a government agency, or, shows the number of 2019 off-exchange only more importantly, may be barred from plans available in New York, Albany, and Erie purchasing from the NYSOH because of counties—along with NYSOH products, some their immigration status. New enrollment on of which may be offered off-exchange in these and off the exchange has helped revive the counties as well. individual market in New York. Although off-exchange membership has declined since FIGURE 1. DISTRIBUTION OF PLANS IN NEW YORK RATING REGION 4, 2020 2,597 On Exchange 2,868 Off Exchange On and Off Exchange 3,611 Source: HIX Compare. Robert Wood Johnson Foundation. Data File, Individual Market. December 2, 2019. https://hixcompare.org/individual-markets.html Notes: New York Rating Region 4 includes Bronx, Kings, New York, Queens, Richmond, Rockland, and Westchester counties. The data in HIX Compare are derived from health plan submissions to the Centers for Medicare & Medicaid Services’ Health Insurance Oversight System, which assigns a separate identification number to each unique QHP product, though many have only minor differences in cost sharing or coverage. U N I TED H OSPITAL FUND | HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET 3 FIGURE 2. DISTRIBUTION OF PLANS IN ALBANY, ERIE, AND NEW YORK COUNTIES, 2020 315 NYSOH / Off- 234 Exchange 188 Off-Exchange Only 104 93 66 Albany Erie New York Source: HIX Compare. Robert Wood Johnson Foundation. Issuer County Level File, Individual Market. December 2, 2012. https://hixcompare.org/individual-markets.html All individual coverage products available on NYSOH website, consumers can determine or off the exchange conform to the actuarial eligibility for public programs and access ACA value targets set out in the ACA, sometimes affordability subsidies, research and compare known as “metal levels,” with catastrophic available plans, check provider networks and plans7 carrying the lowest premiums but the quality ratings, and enroll in coverage. In most out-of-pocket exposure for consumers, addition, counselors at the NYSOH hotline and platinum plans carrying the highest assist consumers in over 170 languages, and premiums but the lowest risk.8 Figure 3 shows in-person assistors are available across the the purchasing patterns of consumers on state to guide potential enrollees through and off the exchange in 2019. Off-exchange the process of signing up for coverage.10 In consumers were more likely to choose the contrast, off-exchange customers are on their lowest- and higher-value plans (catastrophic, own, at least initially. gold, platinum). Those on the exchange were more likely to choose mid-level plans (bronze There is no comprehensive public listing of and silver), which may reflect the fact that the health plans selling off-exchange coverage ACA subsidies are tied to silver plans and can or the products they are offering. Reviewing be used to purchase bronze plans at no or very proprietary information sources for coverage low premium cost.9 shows them to be a mixed bag. One site did a good job of testing consumers’ preferences Shopping for Off-Exchange through a brief online survey and laying out Coverage options on and off the exchange (including some hard-to-find plans), another listed only The NYSOH marketplace helps eligible one off-exchange plan when many more consumers shop in many ways. On the were available, and a third asked for health 4 HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET | U N IT ED H O S PITA L F U ND FIGURE 3. LEVELS OF INDIVIDUAL COVERAGE PURCHASED, ON VS. OFF NY STATE OF HEALTH, 2019 15% 9% 13% 19% 37% 29% 27% 39% 10% 2% Off-Exchange NYSOH Catastrophic Bronze Silver Gold Platinum Source: UHF analysis of off-exchange enrollment data provided by the New York State Department of Financial Services in personal communication, April 2019, and NYSOH enrollment data from the NYSOH Enrollment Report 2019. https://info.nystateofhealth. ny.gov/2019openenrollmentreport information up front, never a good sign.11 Downstate, where public program health Consumers with English proficiency and maintenance organizations play a larger some computer skills can check availability at role, the path to off-exchange coverage is not individual plans’ websites or toll-free hotlines, always clear. Some plans don’t promote their as was the case before the ACA. off-exchange coverage the same way they promote their other coverage, as they focus In upstate markets, where traditional insurers on public programs rather than commercial play a larger role compared to the public products. And sometimes health plans’ program health maintenance organizations product lines change. Empire BlueCross that are more numerous downstate, nearly all BlueShield, which reported over 13,000 plans provide clear information about off- off-exchange enrollees in 2018 (more than exchange coverage on their websites, some its NYSOH total),14 has shifted this business with very user-friendly tools. Two health plans to its public program license HealthPlus HP with large off-exchange enrollment in 2018, for 2020; consumers interested in individual MVP Health Care (12,962)12 and Excellus or family plans are directed to the NYSOH BCBS (13,572),13 clearly differentiate between website, or to dental/vision options.15 The on- and off-exchange products, remind marketplace website for the state’s largest consumers to check eligibility for subsidies NYSOH plan,16 Fidelis Care (103,000 available through NYSOH, offer personal members in 2019), lets online shoppers for assistance and tools to differentiate between “qualified health plans” know that “it is options, and let consumers apply online or also possible to purchase [qualified health by mail. At MVP, consumers with checking plans] off-exchange, or directly from Fidelis,” accounts can enroll online. providing office addresses and a phone number, but not direct enrollment. Visitors to U N I TED H OSPITAL FUND | HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET 5 the website of Healthfirst,17 another popular would be a costly overreach; customers who plan at NYSOH (14,300 qualified health find those NYSOH tools useful even though plan members in 2019), can find a path to they are ineligible for subsidies can and do information about “marketplace leaf and purchase through NYSOH.24 Still, there are leaf premier” plans with a “get a quote” tool some New Yorkers who might benefit from with advice on plans, but without distinction an upgrade, such as those who don’t meet between NYSOH and the off-exchange the “lawfully present” standard necessary market.18 The website for MetroPlus,19 to purchase at NYSOH, or, in these highly another active NYSOH participant, does politicized times, people who want to keep allow visitors interested in off-exchange their distance from “Obamacare” but who coverage to fill out a preliminary application. still want to explore all their coverage options. Websites for insurers like EmblemHealth20 and Following are some potential steps to improve Oscar21 resemble commercial plans upstate: the off-exchange market: visitors are informed about off-exchange coverage and given details about plans and a Remove Off-Exchange Enrollment path to enrollment. Barriers—Starting With the Application As for the availability of child-only coverage, it’s addressed through footnotes at most While NYSOH purchasers must prove that health plan websites, rather than as a separate they are lawfully present in order to obtain listing of products offered with applicable coverage,25 no such requirements apply for rates. Except for Empire BCBS, most health off-exchange purchasers. Instead, under New plans offering dental coverage do so as York’s open enrollment law and regulations,26 part of comprehensive coverage, but dental eligibility for health coverage is generally insurers such as Healthplex, Delta Dental, and available to consumers who are New York Guardian Insurance (a multi-line insurer)22 State residents and live within a health plan’s offer off-exchange stand-alone dental plans service area. Federal regulations outline very and vision plans that they advertise on their limited circumstances under which applicants websites. can be denied.27 Without exception, however, off-exchange health plan applications require potential customers to provide Social Security Making Off-Exchange More of numbers—right up front (Figure 4). a Market for Individuals To one close market observer, the term off- Collecting Social Security numbers from exchange “describes a group of insurance applicants is part of the residue of original products, rather than a distribution channel… ACA Internal Revenue Service regulations28 a ‘what’ rather than a ‘where.’”23 But are requiring providers of minimum essential 71,000 off-exchange purchasers—more than coverage (such as health plans and employers) three times the number of enrollees in the to report tax identification numbers for entire standardized individual market before enrollees, so that the individual responsibility the ACA—enough to constitute a market? requirement could be enforced. But, of course, Slightly different benefit requirements apply the penalty for not purchasing affordable to off-exchange coverage than to the NYSOH, individual coverage was “zeroed out” in and the regulatory setup is slightly different the Tax Cut and Jobs Act of 2017, and as well, since the NYSOH plays less of a role. New York has not enacted a state penalty Building a full-blown infrastructure for an off- provision. Arguably, these regulations exchange market like the one at the NYSOH (embodied in the health plan applications) 6 HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET | U N IT ED H O S PITA L F U ND FIGURE 4. TYPICAL OFF-EXCHANGE COVERAGE APPLICATION FIGURE 4. TYPICAL OFF-EXCHANGE COVERAGE APPLICATION Source: Health plan regulatory filings for 2020. are no longer necessary, and themselves exchange focused on establishing the New violate the guaranteed issue provisions, York residency of applicants—rather than since they effectively bar individuals without work authorization or citizenship. There are Social Security numbers from purchasing many existing processes on which to base new off the exchange—including undocumented requirements. Allowing the use of Individual New Yorkers who are already barred from Taxpayer Identification Numbers29 in addition purchasing through the NYSOH. to Social Security numbers would help, since many immigrants use these numbers to file Many health plans scrubbed Social Security taxes.30 And there are many other examples, numbers from their systems out of privacy such as existing New York State Department and identify theft concerns before the ACA; of Health applications for health programs,31 they now comply with the Internal Revenue documents used in photo ID applications for Service requirements only grudgingly, since New York City residents,32 and the “Green they could be subject to federal penalties. As Light” law requirements recently implemented an important first step in eliminating market in New York that allow undocumented New barriers for noncitizens, the New York State Yorkers to obtain a driver’s license.33 The use Department of Financial Services could issue of these common residency documents, such new guidance for health plans selling off the as residential leases, property tax bills, and U N I TED H OSPITAL FUND | HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET 7 utility bills, makes a good deal of sense and such a consumer guide for standardized would be a fairer way to determine eligibility products before the implementation of for off-exchange coverage. the ACA (Figure 5). Since health plans are required to provide language services to At the same time, the Internal Revenue Service enrollees,38 highlighting the availability of regulations do include some wiggle room. those services for applicants would help Health plans that make reasonable efforts to as well. And providing easy access to the obtain Social Security numbers (such as asking guide and off-exchange training resources for the numbers three separate times within to nonprofit organizations that work with a prescribed time period), for example, are immigrant families would expand the not subject to penalties,34 and the Internal usefulness of the guides, particularly for Revenue Service advises issuers to provide those customers who would prefer a non- birthdates for enrollees when taxpayer governmental window to coverage. identification numbers are unavailable. Prospective enrollees without Social Security It’s Not CHP, but Child-Only and numbers are also advised to provide birthdates Dental Coverage Are Available Off- instead.35 In addition, recent Internal Revenue Exchange Service “transition relief” guidance delays federal reporting of enrollee information New York’s Child Health Plus (CHP) program by issuers once again, and for the first time, is the most generous in the country; even eliminates requirements that issuers provide families with household income exceeding enrollees with tax forms for their own returns, 400% of the federal poverty level can buy as the Internal Revenue Service considers “full premium” coverage with no cost-sharing whether to continue the filings at all, or at all for services. And unlike other NYSOH modify them.36 coverage options like the Essential Plan and qualified health plans, kids are eligible for Creating a Map for Purchasers CHP coverage regardless of their immigration Traveling Off-Exchange status. But there is growing evidence39 of declining rates of children’s coverage Implementing a few simple changes nationally—though not yet in New York— administratively could help prospective which some attribute to the “chilling effect” purchasers a great deal. Creating an of the Trump administration’s immigration easily accessible web page in English and policy on many levels, including the so-called common non-English languages (perhaps “public charge” rule.40 Anecdotally, there is following guidelines in a 2011 executive evidence that families are shying away from order)37 with county-level information on enrollment or disenrolling children from participating health plans, available product CHP, though this program is not even part types (including dental, vision, and child- of the public charge rule. At a recent UHF only coverage), websites, toll-free numbers, roundtable discussion, a counselor described whether broker services are available, and a tearful conversation with a pregnant woman retail locations would be a good start. Such who decided to disenroll from Medicaid a website would help potential purchasers on the advice of their family’s private connect with public program health immigration attorney.41 Noting the availability maintenance organizations, which often offer of child-only coverage off the exchange might lower premiums, expanded language services, help families who are too afraid to enroll their and walk-in centers. The New York State children in CHP or Medicaid, or who are Department of Financial Services maintained advised to disenroll by private attorneys. 8 HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET | U N IT ED H O S PITA L F U ND FIGURE 5. SAMPLE PAGE ON PREMIUM RATES FROM NEW YORK’S 2013 CONSUMER GUIDE FIGURE 5. SAMPLE PAGE ON PREMIUM RATES FROM NEW YORK’S 2013 CONSUMER GUIDE Source: Personal communication with the NYS Department of Financial Services. Boosting the Signal for Off-Exchange associated with financial help for coverage Coverage and the availability of help. Off-exchange is a market segment with an adjective instead of a When NYSOH was launched, experienced real name (even the term “exchange” has been marketing and advertising consultants were replaced by “marketplace”) and without a hired to give New York’s exchange a brand message. During a challenging and worrisome name, and NYSOH has worked diligently to time for New York’s immigrants, an effective sharpen its message to customers. Its current message seems obvious: “Coverage for New message—“You deserve affordable health York State Residents” would send a clear care,” with a secondary emphasis on the signal to noncitizens that they are welcome availability of free “one-on-one” enrollment to purchase off-exchange coverage. Coupling assistance—addressed both the stigma that message with standardized nomenclature U N I TED H OSPITAL FUND | HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET 9 about off-exchange coverage and how it immigrants earned more than 200% of the differs from NYSOH plans would help federal poverty level;46 in Queens County, shoppers find it and inform their choices. with an estimated 120,000 unauthorized residents without coverage, about 58,000 Conclusion owned homes or lived in homes owned by family members, suggesting families with New York policymakers opted to preserve incomes who might be able to afford off- an off-exchange option for health insurance exchange coverage and who might want to coverage, providing some flexibility for protect an important family asset against health plans and more choice for consumers, catastrophic medical expenses.47 including where to purchase coverage. However, enrollment barriers close off access The Trump administration’s far-reaching to many immigrants who do not have other immigration agenda may also be leading some coverage options—one of the main goals of immigrants to consider commercial coverage. preserving the market, but a goal that has The so-called “public charge” regulation,48 clearly been neglected. According to recent though still being challenged in court by New estimates,42 undocumented residents account York’s attorney general, New York City, and for nearly 40% of New York’s uninsured nonprofit groups,49 took effect on February population; addressing the barriers to the off- 24, 2020, after the U.S. Supreme Court lifted exchange market would help this population an injunction on the regulation.50 The rule better access coverage. Certainly, the high includes provisions that assign “strongly cost of unsubsidized coverage in the off- weighted positive factors” for green card exchange market is the biggest barrier for applicants who can show private health those ineligible for the marketplace or public insurance coverage. While some immigrant coverage. Lower-income immigrants would be families who can afford private coverage well served by pending legislation to extend would likely be eligible for a second positive Essential Plan eligibility to those earning factor due to household income under the less than 200% of the federal poverty level regulation, some may seek private coverage regardless of their immigration status.43 But to increase the chances of a successful there is evidence that eliminating barriers to application in the current environment. access might be welcomed by a large portion of the undocumented population in New York There are some risks to highlighting coverage who would not meet Essential Plan income available off the exchange, since lower-income eligibility levels. enrollees might miss out on the chance for NYSOH affordability subsidies. Health plan According to a recent analysis by New websites that include information about off- York City,44 the median income of the exchange coverage appear to have addressed roughly 527,000 undocumented immigrants that issue with prompts that provide is $24,200, indicating that about half of opportunities to double-check on available this population would not be served by an subsidies. And some lower-income enrollees Essential Plan expansion. Similarly, a national who choose off-exchange coverage might miss study of immigrants found that about 20% of out on financial assistance for the uninsured New York State’s noncitizens earned $75,000 from federally qualified health centers with or more, and another 16% earned $50,000 to sliding-scale, income-based payments, or $75,000.45 With regard to the unauthorized hospital financial assistance programs—a population, the same organization found choice faced by citizens as well. Some that about 443,000 unauthorized New York immigrant families might want to consider 10 HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET | U N IT ED H O S PITA L F U ND private coverage with the public charge rule New York policymakers moved quickly taking effect, if only as a temporary bridge to during the pandemic to suspend Medicaid a more affordable permanent arrangement. requirements that could lead to unintentional Other families may be interested in less disenrollment51 and to reopen the Marketplace expensive dental or vision coverage, or to to all eligible applicants during a special replace CHP coverage dropped in (needless) enrollment period. Given the rapid spread fear of the public charge rule, with a more of coronavirus infection and the significant expensive but comprehensive child-only plan costs of treating the disease,52 many New from off-exchange, which does feature free York families might be interested in enrolling preventive care. At the very least, making in off-exchange coverage now, despite the modest investments in the off-exchange costs; moving quickly to eliminate enrollment market and reforming eligibility standards barriers off-exchange would be an important shore up an important potential platform for and logical next step. future affordability initiatives off-exchange. This would also inject a needed dose of equity Acknowledgments into New York’s other individual market, putting immigrants who are not eligible for This work was supported by the New York coverage at NYSOH on the same footing as Community Trust. Sarah Scaffidi, MSc, a other New York residents, and providing them research analyst at United Hospital Fund, with a choice. compiled a detailed profile of immigrant characteristics in New York. U N I TED H OSPITAL FUND | HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET 11 Endnotes 1 NY State of Health. February 20, 2020. NY State of Health Announces Record High Enrollment More than 4.9 Million New Yorkers Enrolled. Press Release. https://info.nystateofhealth.ny.gov/ news/press-release-ny-state-health-announces-record-high-enrollment-more-49-million- new-yorkers 2 Carrns A. October 25, 2013. Health Insurance Options Aren’t Limited to Government Exchanges. The New York Times. https://www.nytimes.com/2013/10/26/your-money/health- insurance-options-arent-limited-to-obamacare-exchanges.html?_r=1& 3 Governor of the State of New York. April 12, 2012. Executive Order No. 42. Establishing the New York Health Benefit Exchange. https://info.nystateofhealth.ny.gov/resource/governor- cuomos-executive-order-number-42 ; statutory adoption in New York Public Health Law, Title VII. 4 New York Insurance Law section 4321. 5 New York Insurance Law Section 4328. 6 Newell P. August 2019. Mile Marker or High Water Mark? Tracking New York’s Progress in Covering the Uninsured. United Hospital Fund. https://uhfnyc.org/publications/publication/ mile-marker-or-high-water-mark-tracking-new-yorks-progress-covering-uninsured/ 7 Only available for purchasers up to age 30, or who qualify for a hardship exemption. 8 For a description of bronze, silver, gold and platinum plans, see Standard Benefit design Cost Sharing Description Chart. April 25, 2019. New York State Department of Financial Services. https://www.dfs.ny.gov/system/files/documents/2019/04/attachment_b_std_products_2020_ cost_sharing_chart_rev.pdf 9 UHF analysis of off-exchange enrollment data provided by the New York State Department of Financial Services in personal communication, April 2019, and NYSOH enrollment data from the NYSOH Enrollment Report 2019. https://info.nystateofhealth. ny.gov/2019openenrollmentreport 10 NYSOH website. https://nystateofhealth.ny.gov/ 11 Proprietary exchanges visited online on December 12, 2019 include, respectively PolicyGenius (https://www.policygenius.com/health-insurance/create_account); ehealthinsurance (https:// www.ehealthinsurance.com/individual-family-health-insurance/plans); and obamacare-plans. com (https://www.obamacare-plans.com/marketplace.html) 12 Enrollment data from MVP Health Care New York Supplement, annual, 2018, New York State Department of Financial Services. Website for MVP Healthcare. https://www. mvphealthcare.com/shop/individuals-and-families/plans/?check_medicaid=no&fwp_ csr_plans=no&fwp_american_indian_plans=no&fwp_under_30_plans=no&fwp_ hsa_options=no%2Cshow-plans-with-hsa-options&county=Schenectady&state= NY&zip=12308&plan_type=individual_family&age_under_19=0&age_19_25=0&age_ over_25=1&skip_fa=yes&fwp_marketplace=direct-from-mvp&fwp_metal_ level=na%2Cbronze%2Csilver%2Cgold%2Cplatinum&household_size=1&household_ income=&age_self=Over+25&action=get_subsidy_eligibility&action=get_subsidy_eligibility 13 Enrollment data Excellus Blue Cross Blue Shield New York Supplement, annual, 2018, New York State Department of Financial Services. Website for Excellus Health Plans. https://www. excellusbcbs.com/plans/individual/compare/offerings?internalSrc=false&county=monroe&reg ion=rochester&coverage=single-dental 12 HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET | U N IT ED H O S PITA L F U ND 14 Enrollment data from Empire Blue Cross Blue Shield New York Supplement, annual, 2018. Website for Empire Blue Cross Blue Shield. https://www.empireblue.com/individual-and- family/ . With respect to declining off-exchange enrollment, representatives of Empire indicated in a personal communication in December 2019 that they had been working to shift membership to NYSOH from the off-exchange market out of concern that enrollees were missing out on available cost sharing and premium subsidies, at the suggestion of the New York State Department of Financial Services. 15 Empire BlueCross BlueShield. https://www.empireblue.com/individual-and-family/new-york- health-insurance/ 16 Enrollment data from NYSOH Enrollment Report 2019; website for Fidelis Care https://www. fideliscare.org/Shop-For-A-Plan/Our-Plans/Qualified-Health-Plans 17 Healthfirst enrollment from NYSOH Enrollment report 2019. Healthfirst website https:// healthfirst.org/get-a-quote/ 18 Healthfirst website: https://healthfirst.org/individual-family-plans/ 19MetroPlus: https://enrollment.metroplus.org/home 20 EmblemHealth website: https://www.emblemhealth.com/content/emblemhealth/home/ plans/individuals-and-families.html 21 Oscar website: https://www.hioscar.com/individuals/plans/?beneficiary=member&fips_ code=061&member_dob=1967-04-16&state=NY&year=2020&zip_code=10019 22 Website for HealthPlex, https://www.healthplex.com/prospective/aca/individuals ; website for Delta Dental, https://www.deltadentalins.com/individuals/plans/ ; and website for Guardian Insurance, https://www.guardiandirect.com/products/dental-insurance 23 Hempstead K. October 24, 2016. The Off-Exchange Individual Market and Small Group Market: New HIX Compare Data. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/ hblog20161024.057190/full/ 24 About 42% of NYSOH’s 271,000 qualified health plan purchasers in 2019 did not receive any financial assistance. https://info.nystateofhealth.ny.gov/sites/default/files/NYSOH%202019%20 Open%20Enrollment%20Report_0.pdf 25 Affordable Care Act section 1312(f)(3). The term “lawfully present” includes U.S. citizens, naturalized citizens and immigrants with certain characteristics or at different stages of the immigrant process. For a guide to immigration status with regards to the marketplace and health coverage, see Health Coverage Crosswalk: Eligibility by Immigration Status. March 2013. Empire Justice Center. https://empirejustice.org/resources_post/health-coverage- crosswalk-eligibility-immigration-status/ 26 New York State Department of Financial Services. November 20, 2017. Guidance Regarding the Federal Health Insurance Market Rules and NYS Insurance Law in Relation to Guaranteed Availability and Renewability. https://www.dfs.ny.gov/docs/insurance/health/market-rules- guide.pdf 27 45 CFR Section 147.104. Guaranteed Availability of Coverage. https://www.law.cornell.edu/cfr/ text/45/147.104 28 26 U.S. Code Section 6055. Reporting of Health Coverage. https://www.law.cornell.edu/ uscode/text/26/6055 29 For background information on Individual Tax Identification Numbers, see https://www.irs. gov/individuals/individual-taxpayer-identification-number. Healthfirst was the only health plan identified which allows use of taxpayer identification numbers for its off-exchange applications. Policy Forms for participating off-exchange health plans were accessed through the National Association of Insurance Commissioners SERFF Filing Access, State of New York. https://filingaccess.serff.com/sfa/home/NY U N I TED H OSPITAL FUND | HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET 13 30 The Institute on Taxation & Economic Policy estimates that 50% to 75% of undocumented immigrants pay personal income taxes either using false Social Security numbers or Individual Tax Identification Numbers, and that undocumented immigrants in New York paid over $1 billion in state and local taxes in 2017, including about $183 million in personal income taxes. Gee LC, et al. March 2017. Undocumented Immigrants’ State & Local Tax Contributions. Institute on Taxation & Economic Policy. 31 New York State Department of Health, Documentation Checklist for Health Insurance. https://www.health.ny.gov/health_care/medicaid/publications/docs/inf/09inf-2att3.pdf 32 For background information on New York City’s ID NYC program, see https://www1.nyc.gov/ site/idnyc/card/documentation.page 33 For background information on New York’s Green Light law, see https://dmv.ny.gov/driver- license/driver-licenses-and-green-light-law 34 U.S. Internal Revenue Service. Questions and Answers on Information Reporting by Health Coverage Providers (Section 6055). https://www.irs.gov/affordable-care-act/questions-and- answers-on-information-reporting-by-health-coverage-providers-section-6055 35 U.S. Internal Revenue Service. Questions and Answer about Reporting Social Security Numbers to Your Health Insurance Company. https://www.irs.gov/affordable-care-act/ questions-and-answers-about-reporting-social-security-numbers-to-your-health-insurance- company 36 U.S. Internal Revenue Service. Notice 2019-63. December 6, 2019. https://www.irs.gov/pub/irs- drop/n-19-63.pdf 37 State of New York, Executive Chamber. Executive Order No. 26. Statewide Language Access Policy. The order calls for translations in the “six most commons non-English languages spoken by individuals with limited-English proficiency in the State of New York, based on United States census data, and relevant to services offered by each such agency.” https:// www.governor.ny.gov/news/no-26-statewide-language-access-policy. 38 Notices of Non-Discrimination are typically provided by health plans on applications or to new enrollees, and include lists of the many languages spoken, as required by Section 1557 of the Affordable Care Act. For one example of such a notice, see https://assets. healthfirst.org/Notice_of_Non-Discrimination?_ga=2.173809963.902751296.1552329687- 545045916.1509387917&v=0419113448 39 Changes in Medicaid and CHIP Enrollment. November 2019. Medicaid and CHIP Payment Advisory Commission. Table A-2. https://www.macpac.gov/wp-content/uploads/2019/11/ Changes-in-Medicaid-and-CHIP-Enrollment.pdf; MACSTATS: Medicaid and CHIP Data Book. December 2019. Medicare and CHIP Payment and Access Commission. Trends. Exhibit 11. https://www.macpac.gov/macstats/trends/ 40 Artiga S, R Garfield and A Damico. September 2019. Estimated Impact of Final Public Charge Inadmissibility Rule on Immigrants and Medicaid Coverage. https://www.kff.org/report- section/estimated-impacts-of-final-public-charge-inadmissibility-rule-on-immigrants-and- medicaid-coverage-key-findings/ 41 No Stone Unturned: Strategies for Enrolling New York’s Eligible but Uninsured and Preserving Coverage Gains. October 23, 2019. Presentations available at https://uhfnyc.org/ news/article/new-yorks-affordable-care-act-marketplace-now-open-business-2020/ 42 Presentation of D. Holahan. New York’s Affordable Care Act Marketplace Now Open for Business for 2020. United Hospital Fund. https://uhfnyc.org/news/article/new-yorks- affordable-care-act-marketplace-now-open-business-2020/ 43 A.5974 (Gottfried)/S.3900 (Rivera). https://www.nysenate.gov/legislation/bills/2019/s3900 14 HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET | U N IT ED H O S PITA L F U ND 44 An Economic Profile of Immigrants in New York City: First Results from NYC Opportunity Experimental Population Estimate. NYC Mayor’s Office for Economic Opportunity. 2018. Access date 10/9/2019. https://www1.nyc.gov/assets/opportunity/pdf/immigrant-poverty- report-2018.pdf 45 Migration Policy Institute. Data Hub. State Immigration Data Profiles. New York. Income and Poverty. https://www.migrationpolicy.org/data/state-profiles/state/income/NY 46 Migration Policy Institute. Data Hub. Profile of the Unauthorized Population: New York. https://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/NY 47 Migration Policy Institute. Data Hub. County Data. Profile of the Unauthorized Population: Queens County, NY. https://www.migrationpolicy.org/data/unauthorized-immigrant- population/county/36081 48 United States Citizenship and Immigrant Services, Department of Homeland Security. Inadmissibility on Public Charge Grounds. August 8, 2019. Final Rule. https://www. federalregister.gov/documents/2019/08/14/2019-17142/inadmissibility-on-public-charge- grounds 49 Make the Road New York et al. against Ken Cuccinelli et al. United States District Court, Southern District of New York. https://ccrjustice.org/sites/default/files/attach/2019/08/ Public%20Charge%20Complaint.pdf; State of New York, City of New York, State of Connecticut, and State of Vermont against United States Department of Homeland Security, et al.. United States District Court, Southern District of New York. https://www.networkforphl. org/resources/state-of-new-york-et-al-v-u-s-department-of-homeland-security/ 50 Supreme Court of the United States. Application (19A785) granted by the Court. January 27, 2020. Department of Homeland Security et al., applicants v. New York, et al. Case numbers (19-3501); (19-3595). https://www.supremecourt.gov/search.aspx?filename=/docket/docketfiles/ html/public/19a785.html 51 New York State Department of Health, Office of Health Insurane Programs. April 2, 2020. General Information System. Coronavirus (COVID-19) Medicaid Eligibility Processes During Emergency Period. https://health.ny.gov/health_care/medicaid/publications/docs/ gis/20ma04.pdf 52 Rae M, Claxton G, Kurani N, McDermott D, and Cox C. March 13, 2020. Potential Costs of Coronavirus Treatment for People with Employer Coverage. Peterson-Kaiser Health System Tracker. https://www.healthsystemtracker.org/brief/potential-costs-of-coronavirus- treatment-for-people-with-employer-coverage/ This model estimated the average costs of inpatient pneumonia admissions for patients with employer-sponsored coverage and major complications or comorbidity to be over $20,000. U N I TED H OSPITAL FUND | HEALT HWATCH: NEW YORK ’ S OF F - EXC HA NG E MA RK ET 15