Essential Plan (EP) Guidance 1.0

Office of Health Insurance Programs
Division of Finance and Rate Setting

Guidance Documents are available in PDF format as well:

EP Guidance 1.0: Information Regarding EP Rate Setting Assumptions and Emergency Out-of-Network Hospital Reimbursement

Date of Issuance: September 10, 2015

The purpose of this document is to provide Information Regarding the Department of Health´s Essential Plan Rate Setting Assumptions and Emergency Out-of-Network Hospital Reimbursement guidance.

Essential Plan Rate Setting Assumptions

  • The Affordable Care Act (ACA) provides states the option to establish a basic health program for:
    • Individuals with incomes between 138-200% of the Federal Poverty Level (FPL) who are ineligible for Medicaid or Child Health Plus (CHP), and do not have access to affordable employer coverage; and
    • Individuals with incomes below 138% of FPL who are ineligible for Medicaid due to immigration status.
  • The EP premium groups, which will align with the nine rating regions used in the Medicaid Managed Care (MMC) program, are as follows:
Rating Group Population % FPL Monthly Premium Ages Premium*
Essential Plan 1 Non-Medicaid/QHP 151-200% FPL $20 + Dental/Vision 19-64 $490.82
Essential Plan 2 Non-Medicaid/QHP 139-150% FPL $0 + Dental/Vision 19-64 $567.72
Essential Plan 3 Aliessa 100-138% FPL $0 21-64 $423.25
Essential Plan 4 Aliessa < 100% FPL $0 21-64 $425.26

* Final Statewide average capitation rate (net of premium) across all regions.

  • Benchmarking assumptions built into rates:
    • EP1 & EP2 (non-Medicaid/QHP) - Medicaid + 20%
    • EP3 & EP4 (Aliessa) - Medicaid
  • Graduate Medical Education assumptions built into rates:
    • Dollars included in EP1 & EP2 (non-Medicaid/QHP) rates
    • Dollars excluded and billed separately by hospital in EP3 & EP4 (Aliessa)
  • Tax assumptions built into rates:
    • Covered Lives Assessment applied along with HCRA Commercial rate of 9.63%

Reimbursement for Emergency Out-of-Network Hospital Services Received by Essential Plan Enrollees

For Aliessa members, the health plan is required to pay the Medicaid default rate as now applies for such members.

For non-Aliessa members, the following guidance applies:

  1. The Affordable Care Act (ACA) establishes minimum reimbursement amounts that health plans must pay for out-of-network emergency services. In addition, New York State Insurance and Public Health Law and regulation currently require insurers and HMOs to hold insureds harmless in the event a provider seeks payment in excess of the combined plan payment and patient in-network deductible, copayment or coinsurance for OON emergency services in a hospital.
  2. As Essential Plan (EP) enrollees have no liability for charges in excess of any applicable in-network cost sharing, it is the expectation of the Department of Health that insurers and hospitals will make best efforts to negotiate resolution of disputes that may arise over appropriate reimbursement for out-of-network emergency services to EP enrollees without involving the enrollee, unless information is needed from the enrollee to make or support a coverage determination. Consistent with this expectation, with respect to such services, DOH discourages:
    • Insurers from issuing payment to patients rather than to the providers in order to avoid the necessity of providers billing patients, and;
    • Hospitals from balance billing patients for charges in excess of payments received from insurers.
  3. Patterns of reimbursement or billing for emergency services received by EP enrollees that hospitals and/or insurers believe to be unreasonable should be brought to the attention of DOH.

EP Guidance 1.1: Federally Qualified Health Center (FQHC) Wrap Payments

Date of Issuance: October 14, 2015

Federal law 42 U.S.C. §1396a (bb)(5)(A) requires states to make supplemental payments to an FQHC or RHC pursuant to a contract between the FQHC and a Managed Care Organization (MCO) and/or Independent Practice Association (IPA) for the amount, if any, that the FQHCs blended Medicaid rate exceeds the amount of payments provided under the managed care contract for the services rendered by the FQHC. Please note that for Essential Plan Rating Groups 3 and 4 (lawfully present Aliessa immigrants 0% - 138% of FPL) the Department of Health (DOH) will continue to issue these supplemental payments to FQHCs.

EP Guidance 1.2: Information Regarding EP Enrollment by Region

Date of Issuance: October 27, 2015

For informational purposes, the Department has developed the following charts to provide Essential Plan ´draft´ enrollment information to MCO´s and hospitals:

EP Eligible Premium Group Percentage by Region
(September 2015 Enrollment)
Region QHP Aliessa Total EP
NYC 24.21% 75.79% 100%
Long Island 57.79% 42.21% 100%
Rest of State 76.27% 23.73% 100%

Regional Percentage of Statewide EP Eligible Beneficiaries
(September 2015 Enrollment)
Region QHP Aliessa Total EP
NYC 44.11% 84.80% 69.32%
Long Island 17.57% 7.88% 11.56%
Rest of State 38.32% 7.32% 19.12%
Total 100% 100% 100%