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New York Health Exchange Profile

New York

Establishing the Exchange

After the New York State legislature failed to pass exchange legislation, Governor Andrew Cuomo (D) signed Executive Order 42 on April 12, 2012, to establish the New York Health Benefit Exchange. In August 2013, the state announced that the online marketplace would be called NY State of Health.

Structure: The Executive Order establishes the New York Health Benefit Exchange “within the Department of Health” and gives the Exchange authority to work in conjunction with the Department of Financial Services and other agencies to carry out requirements of the Affordable Care Act.  

Governance:  Although the Executive Order does not create an independent governing board for the Exchange, it establishes regional advisory committees, consisting of consumer advocates, small business representatives, health care providers, agents, brokers, insurers, labor organizations, and other stakeholders, to advise and provide recommendations on Exchange operations. Over 180 members have been appointed to five regional advisory committees representing Western NY, Central NY/Finger Lakes, Capital District/Mid-Hudson/Northern NY, New York City/Metro, and Long Island. Meetings to collect feedback on Exchange development will take place every 4-8 weeks and began in September 2012.

In July 2012, Governor Cuomo named an Executive Director to head the state’s Exchange. In October 2012, the Exchange released an organizational chart that details leadership positions within the Exchange and how the Exchange will interact with other agencies.

Contracting with Plans: Insurers may participate in the individual marketplace, the SHOP, or both and must offer one standard product at every metal level, in every county of their service area. Insurers must offer a standard catastrophic product, but if there is more than one catastrophic plan offered in a county, QHPs may be allowed to opt out of offering the product. An insurer that offers an out-of-network product in a county’s commercial market must offer an out-of-network product through NY State of Health at the silver and platinum levels in that county (an out-of-network product offers coverage for services provided by health care providers that are not in the insurer’s network). QHPs may choose to offer up to three non-standard plans per metal level and can offer non-standard products in a portion of their service area. Child-only plans, catastrophic products, and required out-of-network products will not count towards the non-standard maximum. Standard products must cover the Essential Health Benefits; however, insurers may substitute benefits in the Preventive/Wellness/Chronic Disease Management and Rehabilitation/Habilitation categories in non-standard product offerings.

In July 2013, the Department of Financial Services (DFS) approved rates for seventeen carriers seeking to offer coverage through NY State of Health, and in August 2013 the marketplace announced the plans that will be available for purchase. All plans will be posted to the marketplace website in September 2013, with open enrollment set to begin October 1, 2013. Plans that will be offered during calendar year 2015 must be recertified by the Department of Health (DOH) and DFS in 2014. Insurers that were not approved to sell through NY State of Health in 2014 will not have another opportunity to apply for marketplace participation until 2015, for Plan Year 2016. 

Insurers must maintain a provider network that is consistent with federal law and DOH managed care network adequacy standards. Each insurer’s county network must include a hospital, a choice of three primary care physicians, and a choice of two of each required specialist provider type; however, more providers may be required based on enrollment and geographic accessibility. Each county network must also fulfill provider type and ratio requirements established through the state’s Provider Network Data System (PNDS) and meet various time and distance standards. Insurers must make a good faith effort to include the essential community providers defined by the federal law in their networks and are required, at a minimum, to include a federally qualified health center and a tribal operated health center in each county network, if available. Behavioral health networks must include individual providers, outpatient facilities, and inpatient facilities that can provide detoxification and rehabilitation services. The DOH will review network adequacy quarterly, on a county-by-county basis.

The DOH currently collects quality data for commercial products, Medicaid, and Child Health Plus through a reporting system called the Quality Assurance Reporting Requirements (QARR). All insurers selling products through NY State of Health will be required to participate in the QARR. QARR data collected will be posted on the DOH website and will be essential to determining the plan quality rankings that will be made available on the marketplace website. Insurers participating on the marketplace must also survey a sample of their members using the standardized Consumer Assessment of Health Care Providers and Systems (CAHPS) tool. The DOH will not require insurers to be accredited in order to participate on the marketplace in 2014 and 2015; however, this requirement will be reconsidered for 2015.

Dental and Vision Benefits: QHPs are required to offer pediatric dental benefits as a separately priced benefit for each standard and non-standard product. However, if there are adequate stand-alone dental products available, QHPs may decide not to offer a pediatric dental product. Stand-alone dental carriers must offer one standard pediatric dental product in each service area county and can elect to offer a high coverage (85% actuarial value) or low coverage (75% actuarial value) plan. Carriers may choose to offer up to two non-standard products, such as adult or family dental, in each service area county.  In August 2013, the marketplace announced the dental plans that will be available for purchase through NY State of Health.

Consumer Assistance and Outreach: New York contracted with an advertising agency to create the marketplace name and logo and to develop a media campaign that will launch on October 1, 2013. The campaign will utilize television, radio, online, and print advertising, as well as social media, to deliver messages tailored to target populations. Marketing materials, such as brochures and fact sheets, will be provided in the nine most common languages spoken in New York. The marketplace is also working to develop partnerships with entities such as local government agencies and advocacy organizations to build public awareness of NY State of Health, educate organizations that work with target populations, and guide potential enrollees towards enrollment.

Navigators and In-Person Assisters (IPAs) are a crucial component of the state’s outreach efforts. In July 2013, the DOH announced that 50 organizations were awarded a total of nearly $27 million in conditional grants to serve as Navigators/IPAs for the marketplace. Grantees will subcontract with 96 entities to perform outreach activities and provide in-person enrollment assistance to individuals, families, and small businesses seeking coverage through NY State of Health. There will be over 430 individual assisters who will provide services in 48 languages. Navigators and IPAs will have the same responsibilities and will undergo training and certification throughout August and September. The marketplace website features a map of assister awardees and subcontractors by county and borough.

New York will build upon its existing call center, New York Health Options, to include marketplace  application support. NY Health Options currently provides general program information, application support, and telephone renewals for Medicaid, Family Health Plus, and Family Planning Benefits Program.  There will be four customer service center facilities that could employ up to 1,325 customer representatives in total. In August 2013, the state launched the NY State of Health website, including a tax credit and premium estimator.

Small Business Health Options Program (SHOP) Exchange: In July 2012, the Department of Health released a report completed by subcontractors evaluating standardizing benefit designs in the SHOP Exchange. Additionally, the state completed analyses on the impact of merging the individual and small-group insurance markets and estimated costs of Exchange development, implementation, and on-going operations. New York decided to limit the size of small employers in the SHOP Exchange to 50 or fewer employees but is considering increasing small group size to 100, on or before 2016.

The SHOP will offer both the employee choice and the employer choice models. Through the employer choice model, employers will be able to offer their employees all products within one metal level, a specific product offered by a specific insurer, multiple products from a specific insurer, or all health insurer products on all metal levels. In order for an employer to enroll in non-HMO options offered through NY State of Health, a minimum of 50% of employees must have health insurance coverage. The employer will be eligible for HMO options only if the 50% participation requirement is not met. 

The Exchange will partner with producers to assist employers with enrolling in New York’s SHOP Exchange. Producers must have an active producer’s license, from the Department of Financial Services, and certification that they have completed educational requirements specific to SHOP. Producer compensation levels will be the same inside and outside the Exchange and the Exchange will not be involved in determining commission levels. Web-brokers will not be used in the SHOP Exchange in 2014, but the option remains open for the future.  

Information Technology (IT): New York intends to establish an integrated, scalable, consumer-centric IT system. The Department of Health released a Funding Availability Solicitation to identify subcontractors to develop an IT infrastructure for the Exchange in 2011. In March 2012, New York awarded the five-year contract for Exchange development to the same state contractor running the state’s billing system for Medicaid. State officials acknowledged that by October 2013, the new system would likely be able to accommodate only eligibility and enrollment for the Exchange and newly eligible Medicaid enrollees. Current Medicaid beneficiaries would initially be processed through the existing system and eventually be moved into the new system. Over time the new system will also incorporate eligibility and enrollment for other social service programs.

New York is also one of 11 states participating in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use. The Department of Health has been working with UX 2014 to determine if the interface can be customized to fit the state’s needs and is also exploring plan selection and how UX 2014 can be used to filter eligible health plans while keeping health information secure.

Essential Health Benefits (EHB): The Affordable Care Act (ACA) requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Exchange Executive Director recommended the state use Oxford EPO as the benchmark plan and the Children’s Health Insurance Program (CHIP) as the pediatric dental and vision supplement. 

Exchange Funding

The Department of Insurance received a federal Exchange Planning grant of $1 million in 2010. The state has since received multiple federal grants. In 2011, the Department of Health received an Early Innovator grant of $27.4 million to develop an exchange information technology infrastructure that could be replicated by other states. The Department has also received three federal Level One Establishment grants: $10.7 million, $48.5 million, and $95 million to fund IT systems, expand consumer assistance, redesign the state’s eligibility and enrollment system, and create an all payer database, hire Exchange executive leadership and staff, develop back-end customer support functions, and conduct consumer outreach and program integration.. In January 2013, the state received a Level Two Establishment Grant for $185.2 million to support outreach and marketing, fund IPA training and certification, purchase an accounting system, and support IT development.

The New York State Health Foundation has contributed to New York’s exchange planning process by funding an information technology gap analysis for the state and numerous reports including, the coordination of Medicaid and the exchange and passive and active purchasing.  

New York, along with nine other states, is receiving technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.

Next Steps

On December 14, 2012, New York received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange. Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time and complying with future guidance and regulations.

For additional information on New York’s exchange planning see: and

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