Essential Plan (EP) Guidance

Office of Health Insurance Programs
Division of Finance and Rate Setting

Guidance Document is available in PDF format as well:

Office of Health Insurance Programs

Essential Plan (EP) Guidance 2.0: Information Regarding EP Rate Setting Assumptions for Fiscal Year 2022

Date of Issuance: June, 25, 2021

The purpose of this document is to provide information in relation to provisions included as part of the Fiscal Year (FY) 2022 Enacted Budget.

Essential Plan Rate Setting Assumptions

  1. The FY 2022 Budget included a full annual investment of $420M gross into provider reimbursement rates for the EP1 (FPL 151% to 200%) and EP2 (FPL 139% to 150%) premium groups to bring rates more in line with Commercial reimbursement for inpatient and outpatient hospital-based services. Based on plan reported data, it is estimated that this increase will result in rates for inpatient and outpatient hospital-based services that are 225% of Medicaid fee for service reimbursement for the same services. Plans should utilize funding to increase provider medical reimbursement rates to improve the quality, accessibility, appropriate utilization, and efficiency of services provided to enrollees. Benchmarking assumptions built into rates will be as follows:
    • Full annual (12 months) funding will be included in June 1, 2021 rates for Calendar Year (CY) 2021. As a result, the $420M investment will be prorated and paid over 7 months. Effective January 1, 2022, and annually thereafter, funding will be paid over 12 months.
    • As a result, for CY 2021 plans and providers may reprocess claims retroactive to January 1, 2021, or alternatively, adjustments could be made to claims prospectively for the 7-month period June 1, 2021 through December 31, 2021 or shorter period if implementation of the adjustments is delayed beyond June 1, 2021. The method of adjustment should reflect the full annual amount of the CY 2021 investment and ultimately be consistent with contractual agreements between the parties.
      • Historical plan reported expenditures will be trended to the rating period and include an additional $420M gross for the provider reimbursement rate investment adjustment.
      • This Plan premium adjustment will be applied to all components of the inpatient and outpatient hospital-based categories of service (e.g. operating, capital, etc.) resulting in the estimated 225% increase noted above.
      • Finally, Graduate Medical Education funding continues to be included as part of the EP1 and EP2 rate assumptions as does the Covered Lives Assessment and HCRA Commercial rate of 9.63%.
    • The FY 2022 Budget also included modifications to member cost sharing which included the following:
      • Effective June 1, 2021, the $20 member premium for EP1 has been removed. EP1 premiums will be adjusted accordingly.
      • Effective June 1, 2021, all EP1 and EP2 members will receive coverage for dental and vision with no monthly premium or cost sharing. EP1 and EP2 premiums will be adjusted accordingly.
    • The FY 2022 Budget also included the establishment of a $200M gross Essential Plan Quality Incentive Pool for participating managed care plans. The incentive will be based on Measurement Year (MY) 2020 results from health plan 2020 Quality Assurance Reporting Requirements (QARR) submission and the most recent CAHPS survey results for their population (additional details will be forthcoming). It is anticipated the incentive will be paid to plans who earn an award in the fourth quarter (Jan. 2022 - March 2022) of FY 2022.

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%