Attorney General issues guidance to New Yorkers facing health insurance changes

Amid changes to New York's Essential Plan, James offers tips on shopping for coverage and avoiding scams

Submitted by the Office of New York Attorney General Letitia James

New York Attorney General Letitia James has released guidance to help New Yorkers understand their health insurance options and avoid scams as major changes to New York's Essential Plan take effect. Beginning July 1, New Yorkers enrolled in the Essential Plan with household incomes over 200% of the federal poverty level will no longer be eligible for that coverage. In the guidance, the Office of the Attorney General (OAG) explains the different health insurance options available to New Yorkers when they can enroll or change plans, key terms to understand when shopping for coverage, and common scams to avoid.

"Losing health insurance can be stressful and confusing, and New Yorkers deserve clear, reliable information as they make decisions about their care," James said. "As federal cuts force changes to health insurance programs across the country, I urge New Yorkers to use our guidance and the free state resources available to find coverage that works for them. No one should be left with unexpected medical bills or pushed into a plan that does not meet their needs because they did not know where to turn."

The Essential Plan is a low-cost Affordable Care Act (ACA) marketplace plan available to some low- and middle-income New Yorkers who are not eligible for employer-sponsored insurance or Medicaid. The Essential Plan offers $0 monthly premiums, no deductibles, and extremely low copays and cost-sharing. As a result of federal funding cuts, New York State of Health has announced plans to eliminate Essential Plan eligibility for New Yorkers earning between 200% and 250% of the federal poverty level. This impacts single New Yorkers making between $31,920 and $39,900, two-person households making $43,280 to $54,100, three-person households making $54,640 to $68,300, and four-person households making $66,000 to $82,500.

James released this guidance to support the approximately 450,000 New Yorkers who are set to lose Essential Plan coverage on July 1. As the guidance explains, New Yorkers can only purchase or change health insurance plans during open enrollment and special enrollment periods triggered by qualifying life events such as losing coverage, moving, getting married, having a baby, or experiencing certain changes in income. The loss of Essential Plan coverage is considered a qualifying event, meaning impacted New Yorkers can enroll in a new health insurance plan through the New York State of Health marketplace any time before Sept. 1. James warns New Yorkers that ACA plans will be more expensive than the Essential Plan and are increasing in price due to the expiration of federal subsidies.

The OAG guidance outlines critical information to know before shopping for health insurance, including the specific benefits that plans must offer under the ACA, such as coverage for preexisting conditions, prescription drugs, mental health and substance use treatment, lab services, and hospital and emergency care. James provides breakdowns on the different types of plans available, such as:

Health maintenance organizations (HMO), which do not cover out-of-network non-emergency care and require referrals, but offer lower out-of-pocket costs;

Preferred provider organizations (PPO), which offer a greater selection of providers and tend not to require referrals, but have higher out-of-pocket costs;

Exclusive provider organizations (EPO), which have a more limited selection of providers and only cover emergency out-of-network care, but do not require referrals and have lower out-of-pocket costs; and

Point of service plans (POS), which cover a larger number of providers but require a primary care provider for care coordination and often require specialist referrals.

When selecting a plan, James urges New Yorkers to check whether their existing providers are in-network and prescriptions are covered, consider the full cost of each plan, and evaluate each plan's star and metal ratings. Star ratings are assigned by the federal government on a scale of one to five based on a plan's overall quality, medical care, member experience, and plan administration. Metal ratings describe the cost breakdown between the consumer and health plan:

Bronze plans generally have the highest annual deductibles and lowest monthly premiums, and require consumers to pay nearly half of the total cost of care even after meeting their deductible;

Silver plans have moderate deductibles and low premiums, and offer 70% coverage after a consumer meets their deductible;

Gold plans offer low deductibles and higher premiums, with 80% of care covered after the deductible is met; and

Platinum plans have the lowest deductibles and highest premiums but cover 90% of all care once the deductible is met.

James also warns New Yorkers to remain vigilant and to avoid enrolling in a scam health plan. New Yorkers should always be cautious of anyone who pressures them to enroll immediately, asks for payment to help renew coverage, promises a plan that sounds too good to be true, or requests personal information without proof that they are certified or authorized to help. In addition, New Yorkers should always check for official logos before completing forms and should only share personal information with trusted, verified sources, such as New York State of Health-certified enrollment assistors or navigators, facilitated enrollers, or city and county employees.

James encourages New Yorkers who are ineligible for government-funded health plans but who cannot afford an ACA plan to explore all options, including hospital financial-assistance programs (required under state law), discount drug cards, NYC Care, prescription drug patient-assistance (PAP) programs, or the Elderly Pharmaceutical Insurance Coverage (EPIC) program for seniors.

New Yorkers who enrolled in health insurance through New York State of Health can get free help renewing or changing coverage from New York State of Health-certified enrollment assistors by visiting nystateofhealth.ny.gov or calling 1-855-355-5777. New Yorkers who enrolled in Medicaid through their county Medicaid office or the New York City Human Resources Administration can also get free help renewing their coverage by contacting the office where they originally enrolled. The New York agencies that administer Medicaid, Child Health Plus, and Essential Plan benefits will never charge New Yorkers to enroll or reenroll.

Anyone who believes they have been misled, scammed, or improperly enrolled in a health insurance plan is encouraged to contact OAG's health care helpline for assistance.