1. Health Care Reform:
What it Means for NY’s
Children and Families
Kinda Serafi, Esq.
Children’s Defense Fund-New York
15 Maiden Lane, Suite 1200
New York, New York 10038
(212) 697-2323
kserafi@cdfny.org

2. Main Components
What does health care reform mean for:
Those who have health insurance now
• Insurance Reform Provisions (2010)
Those who do not have insurance
• Strengthening of public health insurance programs
 Medicaid expansion (2014)
 Child Health Plus protected (at least until 2015)
• Creation of Exchange (2014)
 Marketplace to purchase coverage for those who do not have
employer coverage and are not eligible for public coverage

3. How Health Care Reform Affects
Coverage of New Yorkers
Currently
Uninsured
Newly Insured
Post-Reform
(estimates)
Eligible for
Medicaid now
1.1 million 440,000
Newly eligible for
Medicaid
90,000 70,000
Access to
Exchange
1.04 million 650,000
TOTAL 2.62 million 1.16 million
Table modified from NYS Health Foundation report: Implementing Federal Health Care Reform:
A Roadmap for New York State

4. Insurance Reform
Provisions

5. Insurance Reform:
Ban on Annual or Lifetime Limits
• The law bans “lifetime limits” (Sept 2010)
or “annual limits”(2014) on the amount of
medical coverage an insurer will pay.
• This happens when medical expenses go
over a certain amount and the insurer
informs individual that they are not
covered anymore.

6. Insurance Reform:
Preventive Care
No cost-sharing for preventive care
 Effective Sept 2010 for new plans and 2014
for all plans
 Includes immunizations and mammograms

7. Insurance Reform:
Coverage for Young Adults
• As of September 23, 2010 young adults up
to 26 years of age can stay on or join their
parents’ health insurance plan at group rates.
• In New York State we can continue to buy
slightly more expensive (COBRA-like)
coverage for dependents up to 29.
 Law will continue until September 2010.
 After September 2010, coverage available for
dependents between the ages of 26 and 29.

8. Who? Young adults up to age 26
 If parents have employer-sponsored or private
market insurance (plan must offer family coverage)
 Does not matter whether individual is married,
financially independent, student, state residence
When? September 23, 2010 and thereafter
 During plan’s next open enrollment OR special
enrollment period
Cost? Premiums and packages same for all
 5-year-old child costs the same as 25-year-old
 Estimated 1% hike in premiums by 2013 (OMB)
Insurance Reform:
Coverage for Young Adults

9. Insurance Reform:
Pre-Existing Conditions
Insurers will not be allowed to refuse to pay for bills
just because an individual has a health condition that
may cost more money.
 NY has always prevented insurers from doing this but
insurance companies found a way to drop people while
they were in coverage.
 Children (September 2010)
 Adults (2014)
States will have plans for individuals with pre-
existing medical conditions from 2010-2014
 NY Bridge Plan

10. Insurance Reform:
New York Bridge Plan
Who? Individuals with pre-existing medical conditions
 Must have been uninsured for at least 6 months prior
 No family or dependent coverage
When? Can apply as of August 20, 2010; coverage:
October, 2010
 Until 2014, when insurers are no longer allowed to deny
coverage to adults for pre-existing conditions.
Cost?
 $362 Upstate; $421 Downstate
 Minimal copays (Office visit: $20; emergency room: $100;
preventive care: No copay)

11. Demonstration Projects
Health Homes for Chronically Ill
• Effective January 2011, New York State may elect to reimburse
providers who chronically ill patients select as their “health home” to
improve coordination of care.
Medicaid Community First Option
• Effective October 2011, New York State will have the option to allow
Medicaid recipients with incomes up to150 percent of the federal
poverty level (less than $33,000 a year for a family of four), and who
require institutional level of care, to remain in their homes and
communities.
Pediatric Accountable Care Organizations
• From 2012 to 2016, pediatric providers may be recognized as
pediatric Accountable Care Organizations (ACOs) if they
demonstrate a coordinated delivery system. The incentive payments
offered to Pediatric ACOs will hopefully encourage more providers
to offer a higher standard of care while achieving cost savings.

12. Strengthening of
Public Programs

13. Strengthening of Public Programs:
Medicaid Expansion
Medicaid will be expanded to 133 percent of
the federal poverty level (2014)
Modified Adjusted Gross Income
 Will be a big boon for single and childless couples
who were not previously eligible
 Some children will move from CHP to Medicaid
 Some adults will move from FHP to Medicaid

14. Strengthening of Public Programs:
Child Health Plus Protected
• All uninsured children remain eligible for
Child Health Plus.
• State may not make changes to eligibility
levels or cost-sharing.
Future of the program:
• Child Health Plus program preserved up until
2019.
• Funding preserved up until 2015.

15. Strengthening of Public Programs:
Family Health Plus
For individuals with incomes between
133% and 200% State may create a “Basic
Health Plan”
Uncertain whether Family Health Plus will
become the “Basic Health Plan”

16. Hospice Care
Public health insurance will cover both
hospice care and treatment.
Retroactive to March 23, 2010, children on
Medicaid or Child Health Plus may have
coverage for both hospice care and
curative treatment.

17. The Exchange
Finding health insurance
with “no wrong door”

18. The Exchanges will be like “marketplaces” to purchase
coverage
 Insurance companies will be regulated in this exchange
and all products will have to meet standards.
New Exchanges which must be set up in each state by 2014.
Some flexibility in what Exchange will look like.
 For individuals with no employer coverage and who are
not eligible for public coverage
 Businesses of up to 100 employees will also be able to
buy coverage through the health exchange set up in
New York.
The Exchange:
Overview

19. • Exchanges will have to provide assistance to
make sure people can easily navigate.
 Exchange must be accessible by phone, by internet,
by mail, or in person
• Go through the Exchange regardless of
whether you are eligible for Medicaid or
private coverage.
• Simple and seamless pathway. One
provides limited information and State does
third party database verification.
The Exchange:
Accessing The Exchange

20. The Exchange:
Tax Subsidies and Cost Sharing Limits
• There will be tax credits that are available for
lower and middle income individuals to help
purchase monthly premiums.
• There are monthly premium limits/caps based on
income and family size.
 You’ll be limited to as low as 2% and as high as 9.5% of
your income.
• Out of pocket caps for co-payments and
deductibles.
 The absolute maximum you can pay in one year is roughly
$6000 for individuals and $12,000 for family policies if you
enroll in the “silver level” plan.

21. Income
percentage
of the
federal
poverty
level
Income
Range
(family of 3)
Premium
as a % of
Income
Annual
Premiums
Annual
Caps on
Out of
Pocket
Costs (% of
income
family of 3)
Annual
Caps on
Out of
Pocket
Costs
Total
potential
health
care costs
as a % of
income
(family of 3)
Total
potential
health
care costs
(family of 3)
150% $18,310-
$27,460
4.0% $1,099 14.1% $3,867 18.1% $4,966
151-200% $27,461-
$36,620
6.3% $2,307 10.6% $3,867 16.9% $6,174
201-300% $36,621-
$54,930
9.8% $5,218 10.6% $5,800 20.1% $11,018
300-400% $54,931-
$73,240
9.8% $6,958 10.6% $7,733 20.1% $14,691
The Exchange:
Tax Subsidies and Cost Sharing Limits

22. Immigrants
• Immigrants and undocumented children remain
eligible for Child Health Plus
• Immigrants and undocumented pregnant women
remain eligible for Medicaid
• Immigrants and PRUCOL adults remain eligible for
Medicaid
• For the Exchange:
 Lawfully present immigrants can purchase health insurance
through the exchange, and are eligible for the premium tax
credits.
 Undocumented immigrants are NOT allowed to purchase
private health insurance in the exchanges, even if they are
willing to the full cost for it and are not eligible for the premium
tax credits.

23. Individual Mandates
• Required to purchase coverage if you do not
have it. (2014)
• You’ll pay a small tax penalty – much lower
than many people believe.
• This penalty will be phased in:
There are some exceptions like financial hardship: if you
can prove you simply can’t afford health insurance,
you don’t have to pay a penalty.
2014 the greater of $95 or 1% of income
2015 the greater of $325 or 1% of income
2016 the greater of $695 or 2.5% of income

24. Long Road to Implementation
• Need to share with community what health
care reform means for them
o CDF-NY is developing one-pagers and tool kits and conduct
community trainings
• State needs to start implementing many
health insurance reform changes immediately
• State needs to develop Exchange as portal to
coverage. Many questions to be answered…
• Assistance to consumers in navigating health
care reform