Basic Health Program Workgroup

A "Straw Man" Proposal

  • Presentation also available in Portable Document Format (PDF)

November 21, 2013
Office of Health Insurance Programs
NYS Department of Health


  • Introductions
  • Elements of a BHP Proposal
  • BHP Modeling
  • Next Steps


  • New York State resident
  • Citizen or lawfully present non–citizen
  • Under age 65
  • Not eligible for Medicaid or Child Health Plus
  • Income between 133% – 200% of FPL unless ineligible for Medicaid due to immigration status
  • No access to affordable MEC
  • MAGI Income and household size

Enrollment and Continuity of Coverage

  • Continuous enrollment: Applicants can enroll all year long.
  • Prospective coverage: Coverage is effective on the 1st of the following month with a 15th of the month cut off for applications (as it is in the Marketplace).
  • Continuous eligibility (if permitted by CMS/IRS and funded within BHP allocations).
  • Renewals will be twelve months from the initial determination.
  • Verification follows Exchange rules.

Standard Plans

  • Below 150% of FPL – offer Marketplace Standard Plan Silver CSR level (93–95% AV).
  • 150 – 200% of FPL – offer Marketplace Standard Plan at Silver CSR Level (86–88% AV).
  • Each of these benefit packages needs at least one variation.
  • Issue a plan invitation in 2014.
  Silver – CSR Versions  
(AV = 0.86 to 0.88)
100 – 150% FPL
(AV = 0.93 to 0.95)
Deductible (single) $250 $0
MAXIMUM OUT–OF–POCKET LIMIT (single) includes the deductible $2,000 1,000
COST SHARING – MEDICAL SERVICES $250 per admission $100 per admission
         Outpatient Facility $75 $25
         Surgeon $75 $25
         PCP $15 $10
         Specialist $35 $20
         PT/OT/ST Therapies $25 $15
         ER $75 $50
         Ambulance $75 $50
         Urgent Care $50 $30
         DME/Medical Supplies 10% of cost sharing 5% of cost sharing
         Hearing Aids 10% of cost sharing 5% of cost sharing
         Eyewear 10% of cost sharing 5% of cost sharing

Premium Contributions

  Monthly Premiums Maximum Monthly Premiums
Percentage of FLP Medicaid CHIP BHP (after APTC)
<150% $0 $0 $0 $44 (138%) – $57 (150%)
150–200% NA $9 $30 $57 (150%) – $121 (200%)

Trust Fund

  • The State shall establish a trust fund to receive federal payments for BHP.
  • Trust Fund dollars can only be used to pay plan premiums; excess dollars can be used to reduce consumer premiums and cost–sharing, or to provide additional benefits.

Fund Administrative Costs

  • System modifications
  • Customer Service Center cost allocation
  • Staff cost allocation

Effective Date

  • Enrollment begins October 2015; system modifications prevent an October 2014 date.
  • Are there advantages to allowing enrollment for Medicaid enrollees and the uninsured outside an open enrollment period? Is it permissible by CMS?
  • Can QHP enrollees preserve their APTC if BHP is open for enrollment prior to a QHP open enrollment period?


  • Program is contingent on CMS approval of the blueprint
  • Need flexibility to make modifications required by CMS during Blueprint negotiations
  • No new costs to the State
    • Must generate savings; and
    • Administrative costs must be able to be funded from the savings.

Transition of QHP Enrollees

  • QHP enrollees will transition to BHP at open enrollment.
  • Medicaid enrollees will transition at renewal.
  • How can we maximize coverage retention?

Other Considerations

  • End APTC Premium Assistance Program when BHP coverage is effective.
  • Immigrants that are eligible for BHP will no longer be eligible for Medicaid.

Urban Institute Modeling

  • The Urban Institute will update their model and provide an analysis of BHP:
    • Impact on State costs;
    • Impact on Marketplace enrollment and premiums; and
    • Impact on the uninsured.

Next Steps

  • Next Meeting
    • No Scheduled Meeting
  • Questions? Please contact: Kalin Scott, or (518) 474–8141
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