2014 ADVOCACY AGENDA

New Yorkers for Accessible Health Coverage (NYFAHC) is a statewide coalition of 53 voluntary health organizations and allied groups who serve and represent people with chronic illnesses and disabilities, including cancer, HIV/AIDS, cognitive impairments, multiple sclerosis and epilepsy. Because the conditions affecting the individuals and families we represent do not discriminate between rich and poor, we advocate for accessible, affordable, comprehensive and accountable health insurance for the privately insured, as well as those in need of access to public insurance programs. 

AFFORDABILITY OF COVERAGE

NYFAHC supports Legislation to protect consumers from out-of-network surprise medical bills. The legislation would require insurance companies to meet a set of provider network adequacy standards so fewer New Yorkers would need to see out-of-network doctors or specialists, whether planned or unplanned, and it would allow consumers to go out-of-network when their plan’s provider network does not have a specialist who meets their medical. It would improve disclosure by providers, hospitals, and plans.  It would hold consumers harmless for surprise bills from emergency room or out-of-network charges that were outside of their control and set a fair process for providers and insurers to negotiate over coverage disputes. Many New Yorkers currently face large medical bills that they had no way to prevent. Often, consumers who make every attempt to stay with in-network providers end up receiving out-of-network services. With this legislation, consumers will be protected through a more robust provider network and elimination of surprise medical bills for out-of network care.

NYFAHC supports the adoption of a Basic Health Program in New York which will provide more affordable coverage to adults with income between 138% and 200% of the federal poverty level. People at these income levels are eligible for premium subsidies in New York State of Health, but that could amount to as much as 6.3% of their income.   For a single person with an income of $23,000 that could be $120 per month.  As proposed in the Governor’s Executive Budget, there would be no premium for people with incomes below 150% FPL and a $20 premium for people with incomes between 150% and 200% FPL.  The federal government would provide 95% of the financial assistance enrollees would have received in the New York State of Health to fund the program.  Since New York currently offers public health insurance to low income working adults and poor immigrants through Medicaid, the Executive Budget has booked $300 million for 2015 -2016 by transferring the costs of covering these groups to the federal government and it would benefit lower income people with disabilities, who have not gotten a disability determination, at the same time.

NYFAHC strongly opposes prohibiting a spouse or parent from refusing to financially support their child or spouse in order for that individual to obtain Medicaid.  This proposal will eliminate the longstanding right of “spousal/parental refusal” for vulnerable populations such as severely ill children and low-income seniors. As proposed in the budget, the refusal will only we honored and Medicaid be granted if a parent lives apart from their child or if a spouse lives apart or divorces the potential Medicaid recipient. NYAIL opposes denying Medicaid to these vulnerable populations. If this proposal is enacted it will force low income individuals to institutionalize their loved ones purely for financial reasons, creating a discriminatory institutional bias.

Merge the individual direct pay and small group health insurance pools both inside and outside of the New York State of Health marketplace.  New York currently separates its individual and small group insurance markets, both inside and outside of the marketplace.    This hurts individual consumers who, due to a smaller risk pool and less competition see higher premiums and fewer benefits than those in the small group market.  While an individual mandate is bringing new purchasers into the market and has lowered prices, both affordability and choice for individuals would be even more enhanced by a market merger.  It would also be the best way to ensure an out-of-network option and it would also provide continuity of care during transitions between workplace and individual coverage.  Massachusetts offers an example of a successful market merger. 

QUALITY OF COVERAGE

NYFAHC supports legislation that would extend HMO network adequacy requirements to non-HMO Plans.  Network adequacy should be required for all categories of coverage, including EPOs, PPOs and similar plans and they should be required to cover services outside the network when in-network services are not adequate. 

Expand External Review.  External Review of health plan decisions should be extended to whether something is a covered benefit, reimbursement levels, cost variation caused by “wellness programs”, and adequacy of provider for all products.  The external review system should be opened to large self–insured employer and union plans -- both to increase revenue and provide a more consistent system of appeals across the insurance landscape. 

Establish a publicly available searchable database of all external review decisions.  Currently there is no public database of external review cases.  This makes it difficult for a consumer and those who assist consumers to find information about similar cases.  New York should ensure transparency in the external review system by establishing a searchable data base for public use. 

Establish a remediation program for consumers.  Although the New York State of Health and navigator agencies have done remarkable work in transitioning hundreds of thousands of New Yorkers into new coverage, many consumers, especially those facing unusual circumstances, have been misadvised because of inadequate training of insurance company personnel or others, regarding the coverage options open to them.  Some of them have ended up in policies that are inappropriate for their needs when they had the right to better coverage.  NYFAHC urges the state to set up a remediation program administered by the Department of Financial Services, to enable those who have suffered from such misadvice to switch to the proper coverage retroactively.

Provide Consumers with Plan Quality Information.   The New York State of Health should provide consumers with plan quality information that uses data such as the number of complaints made proportionate to enrollment in the plan or the number of plan decisions that go to external review and are reversed.

Plans should offer out-of-network coverage.  Even if network adequacy and external review appeal processes are improved, many consumers would prefer to purchase an out-of-network option that allows them to use out-of-network providers at an increased cost.  People paying for vital and often life-saving treatments with trusted providers – HIV and cancer specialists, for example – should retain the right to see these providers without bearing the full costs of these services.  The legislature should restore the requirement that insurers offer out-of-network coverage on the individual marketplace or merge the individual and small group markets to accomplish this.  Sole proprietors who lost their out-of-network option when they were migrated to the individual market should at least be offered the same protection that those in the individual market received  which requires HMOs to offer platinum level coverage that includes an out-of-network benefit option to people who had such coverage prior to October 1, 2013. 

ACCESSIBILITY OF COVERAGE

New York State of Health should integrate private commercial coverage and public coverage and be capable of enrolling people in the most beneficial program for which they are eligible.  For people with disabilities, who need comprehensive coverage that meets their needs, it is particularly important that the Marketplace be able to do a thorough evaluation of eligibility that takes into consideration disability or diagnosis related Medicaid such as Medicaid Buy-in, Medicaid Spendown, and the Medicaid Cancer Treatment Program.  Currently coverage is not available to through the New York State of Health for “non-MAGI” populations. The New York State of Health asks if a person has a disability or is blind or needs long term care services may be referred to the local Department of Social Services for an eligibility determination.  An additional question that should be asked in this section is whether the person has a cancer diagnosis so that they can be considered for the Medicaid Cancer Treatment Program. Navigators and in-person assistors need to be trained to be familiar with disability related and cancer diagnosis related Medicaid eligibility, so that they can advise people appropriately pending enrollment functionality for all Medicaid populations through the Exchange.

Provide Robust Consumer Assistance Programs.  The health insurance system is notoriously challenging to understand.  Research shows that fewer than one in four uninsured Americans felt confident they understood nine basic insurance terms like “premium”, “coinsurance”, and “maximum out-of-pocket charges”.[1]  Consumer assistance is therefore a critical resource to protect consumer’s rights and help them find and use their health coverage.  The state should find the resources to fund consumer assistance programs that will help consumers enroll in coverage and help them use it.  NYFAHC supports the “dry appropriation” in the Executive Budget that would enable New York to draw down federal funds for this purpose.

COMPREHENSIVENESS OF COVERAGE

NYFAHC strongly opposes eliminating Provider Prevails. This proposal would repeal an important patient protection in the Medicaid program which restored “prescriber prevails” for several classes of drugs last year. A prescriber, with clinical expertise and knowledge of his or her individual patient, should be able to override a managed care formulary or preferred drug when the plan and prescriber cannot come to an agreement on the prescription.   Different individuals may have very different responses to different drugs in the same class. Sometimes only a particular drug is effective or alternative drugs may have unacceptable side effects.  Prescribers are in the best position to make decisions about what drug therapies are best for their patients.  CIDNY urges the State to recognize the importance of specific prescription drug combinations and protect Provider Prevails.

NYFAHC supports Step Therapy Bill S2711-A/A5214-A.  People with disabilities and serious illnesses often have chronic conditions that require a complex combination of medications.  Sometimes only a particular drug is effective or alternative drugs may have unacceptable side effects.   Sometimes a drug that has been helpful will lose its effectiveness. CIDNY supports passage of legislation that would add a new article to the insurance law which gives prescribers access to a clear and convenient process to override step therapy or fail first restrictions when medically in the best interests of the patient. The prescriber’s treatment decisions would prevail when, in his or her professional judgment, the preferred treatment of the Plan or Pharmacy Benefit Manager is expected to be ineffective or cause an adverse reaction or other harm to the covered person.  The legislation would also limit the duration of a step therapy protocol to the period deemed necessary by the prescribing physician or health care professional to determine its effectiveness or a period of thirty days. 

20 visit limit on Medicaid Physical Therapy, Occupational Therapy, and Speech Therapy should be subject to an override.  The Medicaid Redesign Team adopted the recommendations of its Basic Benefit Review Workgroup that included the principle that decisions on the Medicaid Benefit package would be based on evidence derived from an assessment of effectiveness, benefits, harms, and costs.  Arbitrary visit limits may not make sense and discriminate against people with disabilities.  People who have a stroke may need more than 20 physical therapy visits to regain the function of walking.  Already we have seen a person subjected to this limit who required surgery as a result and then was unable to get the recommended post operative physical therapy due to the limit.  Some people may experience depression when they are unable to gain or regain function that may require therapy or prescription drug treatment.  Medicare provides for an override and Medicaid Utilization Thresholds which have been used in New York have provided a procedure for a physician override.  Such a procedure should be implemented with these limits.  



[1] Long, SK, Kenney, GM, et al (2013) .  The Health Reform Monitoring Survey:  Addressing data gaps to provide timely insights into the Affordable Care Act.  Health Affairs 

A REPORT FROM NYFAHC: THE ACA, WELLNESS PROGRAMS, AND PEOPLE WITH DISABILITIES, JULY 2014