Child Health Plus and Healthy New York (Ins. Law 4326)

Two New York programs, two different gaps

New York runs two state programs that the producer exam pairs together because both exist to cover people the ordinary market leaves out. Child Health Plus covers uninsured children. Healthy NY makes standardized, more affordable group coverage available to small employers with lower-wage workforces. They have different statutes, different regulators and different eligibility tests, and the exam likes to mix them up.

Two side-by-side panels compare New York's Child Health Plus and Healthy New York. The left panel, Child Health Plus, under Public Health Law section twenty-five eleven, is run by the Department of Health, solely since January first, twenty twenty-three. It covers uninsured children whose household income is at or below four hundred percent of the federal poverty level, who are not eligible for Medicaid and have no other health coverage. Newborns are covered if the application is made within sixty days of birth, starting from the first day of the birth month. Its test focuses on the child's household. The right panel, Healthy New York, under Insurance Law section forty-three twenty-six, is overseen by the Department of Financial Services, and every H M O must participate. It serves qualifying small employers with fifty or fewer employees, no group health plan in the prior twelve months, and at least thirty percent of employees earning thirty thousand dollars a year or less, a figure indexed each year. The contract must insure at least half of the employees and provide the essential health benefits package. Its test focuses on the employer's size and payroll. — Child Health Plus tests the child's household; Healthy NY tests the employer.

Child Health Plus (Public Health Law section 2511)

Child Health Plus is New York's children's health insurance program, the state's version of the federal Children's Health Insurance Program. It lives in the Public Health Law, not the Insurance Law.

Who runs it. The commissioner of health establishes the program through contracts with approved organizations, the health plans that actually provide the coverage. Since January 1, 2023 the plan is administered solely by the commissioner of health; the superintendent of financial services' old consultative and approval role no longer applies.
What it covers. Covered health care services, which include primary and preventive care and inpatient hospital care. Coverage does not start until the plan's contracts are in place and the child is actually enrolled.
Who qualifies for the subsidy. A child (in standard program terms, under age 19) who:
lives in a household with income at or below 400% of the federal poverty level;
is not eligible for Medicaid (medical assistance). A child who becomes Medicaid-eligible after enrolling may stay on the subsidy for up to three months while the switch happens; and
has no other health insurance coverage. The applicant attests to the source and nature of any coverage the child has.
What families pay. The state subsidizes the premium. Lower-income families pay nothing and higher-income families within the limit pay a modest monthly premium on a sliding scale.
Newborns. A newborn is presumed eligible if a completed, signed application is submitted within 60 days of birth, and once eligibility is determined the baby is enrolled retroactively to the first day of the month of birth.
Renewals. If a recertification application is incomplete, the child stays presumptively eligible for up to two months while the missing information is gathered, and is disenrolled if it never arrives.
Approved organizations may also participate as qualified health plans in the state's Affordable Care Act exchange, and families can apply through that marketplace.

Healthy NY (Insurance Law section 4326)

Healthy NY was created by the Health Care Reform Act of 2000 and is overseen by the Department of Financial Services. Section 4326 sets up standardized health insurance contracts for qualifying small employers, to encourage small businesses to offer coverage to their employees.

Which carriers. Participation is mandatory for every HMO, which has had to offer qualifying group contracts since January 1, 2001. Article 43 nonprofit corporations and Article 42 insurers may join voluntarily, and if they do they can be reimbursed from the program's stop-loss funds on the same terms as HMOs.
Who is a qualifying small employer. All three tests must be met:

No more than 50 employees;
No group health insurance covering employees during the 12 months before applying. The superintendent may stretch this look-back to 18 months to stop employers dropping existing coverage to switch in; and
At least 30% of employees earn $30,000 a year or less, a wage figure that is adjusted every July 1 by the change in the federal poverty level.

Participation. The contract must insure at least 50% of the employees.
Staying qualified. If the employer later buys any other expense-reimbursed or prepaid health coverage for its employees, it ceases to be a qualifying small employer.
Benefits. The contract must cover the essential health benefits package defined in the Insurance Law.
Employer share. As a program rule, the employer must pay at least half of the premium.

Exam tip: Child Health Plus is about the child's household income and the Department of Health. Healthy NY is about the employer's size and payroll and the Department of Financial Services.

What to remember

Match the program to its test. A family asking about free or low-cost coverage for an uninsured child is a Child Health Plus case. A 20-person business that has had no group plan for a year and pays many of its workers modest wages is a Healthy NY case.