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Protecting and Preserving Health Benefits for NY State Residents


Health Care PAC

In 2009, then attorney general Andrew Cuomo settled a case in which he sued New York health Insurers over their inaccurate determination of usual physician fees.  The insurers were using “Ingenix”, a flawed system owned and controlled by giant health insurer United Healthcare, which led them to make inappropriately low payments.  Consumers were left to pay the balance, which was usually significant.  As a result of the legal settlement a more accurate system called “Fairhealth” was created.


New York insurers are now undoing the Governor’s consumer-friendly settlement by all, simultaneously, switching their PPO plans from Fairhealth fees to fees tied to various Medicare formulations.  Consumers may not understand that these new “out-of-network benefits” for which they pay higher premiums or accept lower salaries to obtain, are not what they appear, and reimburse little more than lower-cost HMO’s that only pay for “in-network” care.

We looked at 15 common procedures done in several of the largest counties in New York state, and compared the specific “benefits” in the old versus the new plans.  What we found was that while the traditional PPO plans provided roughly 70-80% of the cost of service, the new plans cover at most only 5-20% of the cost.  Worse yet, depending on the patient’s deductible, the new plans provide no coverage at all, leaving the patient responsible for the entire bill!  Of note, the insurance companies are now charging consumers and businesses about the same amount for these new plans, even though they should be charging no more than the standard HMO plans.  The results of this scheme are that consumers and businesses are being seriously misled, and New York health insurance companies, whose annual profits total more than one billion dollars per year, will reap a windfall profit.


The year 2014 has brought further confusion with the introduction of Obama Care Health Exchange markets where patients can shop for an insurance plan.  These plans purport to offer better coverage for lower premiums but in order to offer lower premium plans, the insurance companies include higher deductibles – as much as $6-10,000, and many are selling plans that reimburse services at Medicaid rates.  Many doctors cannot afford to participate in these plans; as a result, patients cannot obtain the highest quality of care from the specialists they may need to see. In fact many insurers have added physicians to their networks without the physicians’ agreement or consent. 


Legislation was passed as part of the New York State Budget in 2014 that will hopefully increase transparency on the part of insurance companies, and increase availability of meaningful health insurance coverage for out of network services in the private insurance market.  Currently there are no out of network insurance requirements for the exchange market, and we will continue to fight to ensure that New Yorkers who purchase insurance through the health exchange have the right to the same benefits and choices as New Yorkers with insurance through the private market.                 
New York Health Care PAC is committed to supporting members of the New York Legislature who stand behind good policies that ensure fair costs to consumers.

We hope that both Republicans and Democrats can come together to help millions of New Yorkers preserve and strengthen the health coverage they expect and pay for. It’s only fair.




Call 516-442-2241 for more information or email us at nyhealthcarepac@gmail.com