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Healthy NY

Healthy NY. NYS Insurance Department Health Bureau. Approximately 2.5 million uninsured 85% uninsured are adults As high as 1 in 4 uninsured in NYC (1.8 M) Most are employed Nearly 9 out of 10 uninsured workers do not have access to employer sponsored coverage

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Healthy NY

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  1. Healthy NY NYS Insurance Department Health Bureau

  2. Approximately 2.5 million uninsured 85% uninsured are adults As high as 1 in 4 uninsured in NYC (1.8 M) Most are employed Nearly 9 out of 10 uninsured workers do not have access to employer sponsored coverage 52% of uninsured workers are at employers of less than 25 New York State

  3. Community Rating & Open Enrollment Small group market has mandated benefits (law sets a minimum standard) Standardized individual market no choice of benefit packages very comprehensive very expensive New York State

  4. Individual market experience Anti-selection Ever worsening experience Ever increasing premiums

  5. Use of tobacco funds Reinsurance to reduce premiums Market-based initiative Does not appear like a public program Small businesses Sole proprietors Individuals Eligibility criteria Uninsured Most vulnerable / low income / low wage Healthy NY

  6. Eligibility • Small businesses - Profile • 50 or fewer employees • At least 30% of employees earn $38,000* or less in annual wages • Employer has not provided insurance in past 12 months • has not contributed more than a de minimus amount per month per employee for coverage in past 12 months ($50/$75) * adjusted annually

  7. Eligibility • Individuals & Sole Proprietors • < 250% of FPL • Employed in past year (or spouse has been) • Not eligible for employer provided insurance • Ineligible for Medicare • Uninsured for past 12 months OR lost coverage due to certain reasons: divorce, separation, death, change/lose job, change residence, loss of eligibility, reached max age for dependent coverage, or other coverage was COBRA or other public programs

  8. Program Design • Insurance at a reduced premium • Premium Reduction • Benefit Package Design • Pooling • Reinsurance (stop-loss) • Health plans are reimbursed a portion of claims paid on behalf of member • Public – Private Partnership

  9. Benefit Package • Standardized – all health plans offer the same benefit package. • Started with small group benefits (mandated) and eliminated 3 of them: • Home health care • Chiropractic • Outpatient alcohol and substance abuse treatment • Newly enacted mandates not added

  10. Benefit Package • Optional limited prescription drug benefit ($3,000 per person per year) • Benefits modified slightly in 2007 • Now include post-hospital / post surgical home health and PT

  11. Pooling Experience is pooled together Individual premium rate is same as group rate Small employers Sole proprietors Individuals

  12. Reinsurance(original level) $0 for claims over $100,000 $100,000 Reimbursement up to 90% Claims $30,000 $0 for claims under $30,000

  13. Current Reinsurance $0 for claims over $75,000 $100,000 $75,000 Reimbursement up to 90% Claims $30,000 $0 for claims under $5,000 $5,000

  14. Stop-loss PMPM Claims 2001 $ 115,900 2002 $ 715,000 2003 $ 13.3 M 2004 $ 34.5 M 2005 $ 61.7 M 2006 $ 92 M 2007 $123.3 M $ 37 $ 47 $ 54 $ 62 $ 70

  15. Other Elements • All HMOs are required to participate, other health plans may participate voluntarily. • We have state-wide coverage • Employs managed care concepts • We did not have to contract w/ health plans • Creates a level playing field • Applicants apply directly to the HMOs • Marketing is done by the State

  16. What We’ve Learned • Price is critical • Price sensitive businesses and individuals • Must be affordable in order to attract new lives • Premium savings can be significant: 35-40% compared to other small group policies 60-80% compared to individual coverage

  17. What We’ve Learned • Healthier population than expected • SL claims corridors: lowered • Flexibility here is critical • True costs are lower than you think • Savings for other, more expensive programs • Generates premium tax revenue, covered lives assessment • Operates on reimbursement basis (pay the bills next year)

  18. What We’ve Learned • Recognize indirect benefits of program • Rejuvenated private marketplace discussions • interest in new products for small groups • Cross-education of other programs • Family Health Plus, Child Health Plus, M/A • Programs can work together to educate broadly • Don’t be overly rigid or complex • Don’t crowd-out your target • Keep it simple – too many eligibility rules will confuse

  19. www.healthyny.com • More info on the program • Including premium rates, applications, guidance • Annual Reports on the HNY program are online • 2003, 2004, 2005, 2006 and 2007 reports available • program growth, enrollment trends, claims data, pricing impact, feedback from enrollees and health plans

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