The associated press release can be found here
Note from Tony Shih, President of UHF
As in many organizations across New York, normal work life at UHF came to an uneasy end on March 13, 2020, when we began remote work without fully knowing the depth of the crisis that awaited us. Since then, with a number of completed projects in the pipeline and much other ongoing work put on hold, we have prioritized work related to COVID-19. This includes the creation of a resource page that features a UHF consumer guide for maintaining or finding new health coverage during the pandemic, resources for parents and pediatricians, and a series of commentaries presenting views on the impact of coronavirus from all parts of the health care system.
Resuming normal work life may still be weeks or even months away, but UHF will continue to produce work consistent with our mission to build a more effective health care system for New Yorkers. This HealthWatch report from our Health Insurance Project provides an analysis of the off-exchange individual market and suggests some common-sense improvements that could be made. One of the recommendations—eliminating the enrollment barriers that prevent undocumented immigrants (ineligible to shop at the NY State of Health Marketplace) from buying coverage at their own expense in the off-exchange market—is a particularly timely one during the current pandemic and statewide effort to get everyone covered.
Please stay safe.
—Tony Shih, MD, MPH
President, United Hospital Fund
New York’s Affordable Care Act marketplace, NY State of Health, capped its seventh annual open enrollment period with an announcement that nearly five million state residents had signed up for coverage in 2020, including about 273,000 purchasers of qualified health plans in its individual market component, both high-water marks.1 Enrollment occurring during the special coronavirus open enrollment period will add to those totals. New York’s other source for individual coverage—the off-exchange market—has contributed to the overall improvement of the individual market in New York, but membership has been declining of late. At the same time, a Trump administration immigration regulation that took effect on February 24, 2020, could lead noncitizens to drop public coverage or seek commercial coverage. This issue brief examines the off-exchange market and presents some options for a timely tune-up, with a focus on barriers that prevent noncitizens from enrolling off-exchange, a grave concern during the current coronavirus pandemic.
Background
New York policymakers and regulators made dozens of decisions when implementing the ACA in 2014, including whether to create a state exchange or rely on a federal one instead. For states like New York that opted to create their own exchange, a second decision followed: whether the exchange would be the only market for all individual coverage, including public programs, or whether commercial coverage would be available to individuals “off-exchange.” Vermont and the District of Columbia2 made their exchanges the sole source for individual and small group coverage, allowing these smaller states to aggregate the largest number of covered lives within their marketplaces. All other states establishing their own exchanges, however, opted to allow off-exchange markets. In New York,3 this helped assuage health plans’ fears that an unsuccessful launch of the state exchange would leave them without an outlet to sell products, it preserved an option for those who found it more convenient to purchase coverage directly from a plan, and, importantly, it retained a market for individuals who were ineligible to purchase through an exchange because of their immigration status.
ACA requirements, actions by New York regulators and policymakers, and market responses by insurers have all shaped the coverage that is available off the exchange. State policymakers took steps to ensure that individual products would be available for purchase off the exchange by restructuring an existing law. Before 2014, health maintenance organizations4 operating in New York were required to issue two standardized individual market products. In 2014, new legislation enacted in New York required most health maintenance organizations (or their affiliated companies) to offer individual products meeting ACA standards for qualified health plans. Insurers that chose to participate in the NYSOH were required to also offer at least one product in each “metal category” off the exchange as well.5 However, specially licensed health maintenance organizations that focused on public programs were allowed greater discretion on which markets to enter. The ACA and New York rules also required health plans to offer child-only plans, with premiums set at 41.2% of the premium for single individual coverage. Finally, one of the oft-overlooked byproducts of the ACA is that dental, vision, and combined dental vision coverage—through both dental-only carriers and insurers offering comprehensive coverage—became widely available for the first time both as part of comprehensive coverage and on a stand-alone basis through the NYSOH and off it.
New York’s Off-Exchange Individual Market in 2019
Some health plans participate in the off-exchange market because they have a little more leeway with benefit design than with products offered through the NYSOH. By the same token, some consumers may be attracted to off-exchange products, may prefer to purchase directly from a health plan rather than a government agency, or, more importantly, may be barred from purchasing from the NYSOH because of their immigration status. New enrollment on and off the exchange has helped revive the individual market in New York. Although off-exchange membership has declined since its peak in 2014 (133,356 enrollees), 71,700 enrollees were covered under off-exchange individual policies in 2019,6 about 20% of total individual enrollment. According to one detailed analysis of product offerings nationally (Figure 1), plenty of off-exchange products were available in New York State in the rating region that includes New York City and some suburban counties. Figure 2 shows the number of 2019 off-exchange only plans available in New York, Albany, and Erie counties—along with NYSOH products, some of which may be offered off-exchange in these counties as well.
All individual coverage products available on or off the exchange conform to the actuarial value targets set out in the ACA, sometimes known as “metal levels,” with catastrophic plans7 carrying the lowest premiums but the most out-of-pocket exposure for consumers, and platinum plans carrying the highest premiums but the lowest risk.8 Figure 3 shows the purchasing patterns of consumers on and off the exchange in 2019. Off-exchange consumers were more likely to choose the lowest- and higher-value plans (catastrophic, gold, platinum). Those on the exchange were more likely to choose mid-level plans (bronze and silver), which may reflect the fact that ACA subsidies are tied to silver plans and can be used to purchase bronze plans at no or very low premium cost.9
Shopping for Off-Exchange Coverage
The NYSOH marketplace helps eligible consumers shop in many ways. On the NYSOH website, consumers can determine eligibility for public programs and access ACA affordability subsidies, research and compare available plans, check provider networks and quality ratings, and enroll in coverage. In addition, counselors at the NYSOH hotline assist consumers in over 170 languages, and in-person assistors are available across the state to guide potential enrollees through the process of signing up for coverage.10 In contrast, off-exchange customers are on their own, at least initially.
There is no comprehensive public listing of the health plans selling off-exchange coverage or the products they are offering. Reviewing proprietary information sources for coverage shows them to be a mixed bag. One site did a good job of testing consumers’ preferences through a brief online survey and laying out options on and off the exchange (including some hard-to-find plans), another listed only one off-exchange plan when many more were available, and a third asked for health information up front, never a good sign.11 Consumers with English proficiency and some computer skills can check availability at individual plans’ websites or toll-free hotlines, as was the case before the ACA.
In upstate markets, where traditional insurers play a larger role compared to the public program health maintenance organizations that are more numerous downstate, nearly all plans provide clear information about off-exchange coverage on their websites, some with very user-friendly tools. Two health plans with large off-exchange enrollment in 2018, MVP Health Care (12,962)12 and Excellus BCBS (13,572),13 clearly differentiate between on- and off-exchange products, remind consumers to check eligibility for subsidies available through NYSOH, offer personal assistance and tools to differentiate between options, and let consumers apply online or by mail. At MVP, consumers with checking accounts can enroll online.
Downstate, where public program health maintenance organizations play a larger role, the path to off-exchange coverage is not always clear. Some plans don’t promote their off-exchange coverage the same way they promote their other coverage, as they focus on public programs rather than commercial products. And sometimes health plans’ product lines change. Empire BlueCross BlueShield, which reported over 13,000 off-exchange enrollees in 2018 (more than its NYSOH total),14 has shifted this business to its public program license HealthPlus HP for 2020; consumers interested in individual or family plans are directed to the NYSOH website, or to dental/vision options.15 The marketplace website for the state’s largest NYSOH plan,16 Fidelis Care (103,000 members in 2019), lets online shoppers for “qualified health plans” know that “it is also possible to purchase [qualified health plans] off-exchange, or directly from Fidelis,” providing office addresses and a phone number, but not direct enrollment. Visitors to the website of Healthfirst,17 another popular plan at NYSOH (14,300 qualified health plan members in 2019), can find a path to information about “marketplace leaf and leaf premier” plans with a “get a quote” tool with advice on plans, but without distinction between NYSOH and the off-exchange market.18 The website for MetroPlus,19 another active NYSOH participant, does allow visitors interested in off-exchange coverage to fill out a preliminary application. Websites for insurers like EmblemHealth20 and Oscar21 resemble commercial plans upstate: visitors are informed about off-exchange coverage and given details about plans and a path to enrollment.
As for the availability of child-only coverage, it’s addressed through footnotes at most health plan websites, rather than as a separate listing of products offered with applicable rates. Except for Empire BCBS, most health plans offering dental coverage do so as part of comprehensive coverage, but dental insurers such as Healthplex, Delta Dental, and Guardian Insurance (a multi-line insurer)22 offer off-exchange stand-alone dental plans and vision plans that they advertise on their websites.
Making Off-Exchange More of a Market for Individuals
To one close market observer, the term off-exchange “describes a group of insurance products, rather than a distribution channel… a ‘what’ rather than a ‘where.’”23 But are 71,000 off-exchange purchasers—more than three times the number of enrollees in the entire standardized individual market before the ACA—enough to constitute a market? Slightly different benefit requirements apply to off-exchange coverage than to the NYSOH, and the regulatory setup is slightly different as well, since the NYSOH plays less of a role. Building a full-blown infrastructure for an off-exchange market like the one at the NYSOH would be a costly overreach; customers who find those NYSOH tools useful even though they are ineligible for subsidies can and do purchase through NYSOH.24 Still, there are some New Yorkers who might benefit from an upgrade, such as those who don’t meet the “lawfully present” standard necessary to purchase at NYSOH, or, in these highly politicized times, people who want to keep their distance from “Obamacare” but who still want to explore all their coverage options. Following are some potential steps to improve the off-exchange market:
Remove Off-Exchange Enrollment Barriers—Starting With the Application
While NYSOH purchasers must prove that they are lawfully present in order to obtain coverage,25 no such requirements apply for off-exchange purchasers. Instead, under New York’s open enrollment law and regulations,26 eligibility for health coverage is generally available to consumers who are New York State residents and live within a health plan’s service area. Federal regulations outline very limited circumstances under which applicants can be denied.27 Without exception, however, off-exchange health plan applications require potential customers to provide Social Security numbers—right up front (Figure 4).
Collecting Social Security numbers from applicants is part of the residue of original ACA Internal Revenue Service regulations28 requiring providers of minimum essential coverage (such as health plans and employers) to report tax identification numbers for enrollees, so that the individual responsibility requirement could be enforced. But, of course, the penalty for not purchasing affordable individual coverage was “zeroed out” in the Tax Cut and Jobs Act of 2017, and New York has not enacted a state penalty provision. Arguably, these regulations (embodied in the health plan applications) are no longer necessary, and themselves violate the guaranteed issue provisions, since they effectively bar individuals without Social Security numbers from purchasing off the exchange—including undocumented New Yorkers who are already barred from purchasing through the NYSOH.
Many health plans scrubbed Social Security numbers from their systems out of privacy and identify theft concerns before the ACA; they now comply with the Internal Revenue Service requirements only grudgingly, since they could be subject to federal penalties. As an important first step in eliminating market barriers for noncitizens, the New York State Department of Financial Services could issue new guidance for health plans selling off the exchange focused on establishing the New York residency of applicants—rather than work authorization or citizenship. There are many existing processes on which to base new requirements. Allowing the use of Individual Taxpayer Identification Numbers29 in addition to Social Security numbers would help, since many immigrants use these numbers to file taxes.30 And there are many other examples, such as existing New York State Department of Health applications for health programs,31 documents used in photo ID applications for New York City residents,32 and the “Green Light” law requirements recently implemented in New York that allow undocumented New Yorkers to obtain a driver’s license.33 The use of these common residency documents, such as residential leases, property tax bills, and utility bills, makes a good deal of sense and would be a fairer way to determine eligibility for off-exchange coverage.
At the same time, the Internal Revenue Service regulations do include some wiggle room. Health plans that make reasonable efforts to obtain Social Security numbers (such as asking for the numbers three separate times within a prescribed time period), for example, are not subject to penalties,34 and the Internal Revenue Service advises issuers to provide birthdates for enrollees when taxpayer identification numbers are unavailable. Prospective enrollees without Social Security numbers are also advised to provide birthdates instead.35 In addition, recent Internal Revenue Service “transition relief” guidance delays federal reporting of enrollee information by issuers once again, and for the first time, eliminates requirements that issuers provide enrollees with tax forms for their own returns, as the Internal Revenue Service considers whether to continue the filings at all, or modify them.36
Creating a Map for Purchasers Traveling Off-Exchange
Implementing a few simple changes administratively could help prospective purchasers a great deal. Creating an easily accessible web page in English and common non-English languages (perhaps following guidelines in a 2011 executive order)37 with county-level information on participating health plans, available product types (including dental, vision, and child-only coverage), websites, toll-free numbers, whether broker services are available, and retail locations would be a good start. Such a website would help potential purchasers connect with public program health maintenance organizations, which often offer lower premiums, expanded language services, and walk-in centers. The New York State Department of Financial Services maintained such a consumer guide for standardized products before the implementation of the ACA (Figure 5). Since health plans are required to provide language services to enrollees,38 highlighting the availability of those services for applicants would help as well. And providing easy access to the guide and off-exchange training resources to nonprofit organizations that work with immigrant families would expand the usefulness of the guides, particularly for those customers who would prefer a non-governmental window to coverage.
It’s Not CHP, but Child-Only and Dental Coverage Are Available Off-Exchange
New York’s Child Health Plus (CHP) program is the most generous in the country; even families with household income exceeding 400% of the federal poverty level can buy “full premium” coverage with no cost-sharing at all for services. And unlike other NYSOH coverage options like the Essential Plan and qualified health plans, kids are eligible for CHP coverage regardless of their immigration status. But there is growing evidence39 of declining rates of children’s coverage nationally—though not yet in New York—which some attribute to the “chilling effect” of the Trump administration’s immigration policy on many levels, including the so-called “public charge” rule.40 Anecdotally, there is evidence that families are shying away from enrollment or disenrolling children from CHP, though this program is not even part of the public charge rule. At a recent UHF roundtable discussion, a counselor described a tearful conversation with a pregnant woman who decided to disenroll from Medicaid on the advice of their family’s private immigration attorney.41 Noting the availability of child-only coverage off the exchange might help families who are too afraid to enroll their children in CHP or Medicaid, or who are advised to disenroll by private attorneys.
Boosting the Signal for Off-Exchange Coverage
When NYSOH was launched, experienced marketing and advertising consultants were hired to give New York’s exchange a brand name, and NYSOH has worked diligently to sharpen its message to customers. Its current message—“You deserve affordable health care,” with a secondary emphasis on the availability of free “one-on-one” enrollment assistance—addressed both the stigma associated with financial help for coverage and the availability of help. Off-exchange is a market segment with an adjective instead of a real name (even the term “exchange” has been replaced by “marketplace”) and without a message. During a challenging and worrisome time for New York’s immigrants, an effective message seems obvious: “Coverage for New York State Residents” would send a clear signal to noncitizens that they are welcome to purchase off-exchange coverage. Coupling that message with standardized nomenclature about off-exchange coverage and how it differs from NYSOH plans would help shoppers find it and inform their choices.
Conclusion
New York policymakers opted to preserve an off-exchange option for health insurance coverage, providing some flexibility for health plans and more choice for consumers, including where to purchase coverage. However, enrollment barriers close off access to many immigrants who do not have other coverage options—one of the main goals of preserving the market, but a goal that has clearly been neglected. According to recent estimates,42 undocumented residents account for nearly 40% of New York’s uninsured population; addressing the barriers to the off-exchange market would help this population better access coverage. Certainly, the high cost of unsubsidized coverage in the off-exchange market is the biggest barrier for those ineligible for the marketplace or public coverage. Lower-income immigrants would be well served by pending legislation to extend Essential Plan eligibility to those earning less than 200% of the federal poverty level regardless of their immigration status.43 But there is evidence that eliminating barriers to access might be welcomed by a large portion of the undocumented population in New York who would not meet Essential Plan income eligibility levels.
According to a recent analysis by New York City,44 the median income of the roughly 527,000 undocumented immigrants is $24,200, indicating that about half of this population would not be served by an Essential Plan expansion. Similarly, a national study of immigrants found that about 20% of New York State’s noncitizens earned $75,000 or more, and another 16% earned $50,000 to $75,000.45 With regard to the unauthorized population, the same organization found that about 443,000 unauthorized New York immigrants earned more than 200% of the federal poverty level;46 in Queens County, with an estimated 120,000 unauthorized residents without coverage, about 58,000 owned homes or lived in homes owned by family members, suggesting families with incomes who might be able to afford off-exchange coverage and who might want to protect an important family asset against catastrophic medical expenses.47
The Trump administration’s far-reaching immigration agenda may also be leading some immigrants to consider commercial coverage. The so-called “public charge” regulation,48 though still being challenged in court by New York’s attorney general, New York City, and nonprofit groups,49 took effect on February 24, 2020, after the U.S. Supreme Court lifted an injunction on the regulation.50 The rule includes provisions that assign “strongly weighted positive factors” for green card applicants who can show private health insurance coverage. While some immigrant families who can afford private coverage would likely be eligible for a second positive factor due to household income under the regulation, some may seek private coverage to increase the chances of a successful application in the current environment.
There are some risks to highlighting coverage available off the exchange, since lower-income enrollees might miss out on the chance for NYSOH affordability subsidies. Health plan websites that include information about off-exchange coverage appear to have addressed that issue with prompts that provide opportunities to double-check on available subsidies. And some lower-income enrollees who choose off-exchange coverage might miss out on financial assistance for the uninsured from federally qualified health centers with sliding-scale, income-based payments, or hospital financial assistance programs—a choice faced by citizens as well. Some immigrant families might want to consider private coverage with the public charge rule taking effect, if only as a temporary bridge to a more affordable permanent arrangement. Other families may be interested in less expensive dental or vision coverage, or to replace CHP coverage dropped in (needless) fear of the public charge rule, with a more expensive but comprehensive child-only plan from off-exchange, which does feature free preventive care. At the very least, making modest investments in the off-exchange market and reforming eligibility standards shore up an important potential platform for future affordability initiatives off-exchange. This would also inject a needed dose of equity into New York’s other individual market, putting immigrants who are not eligible for coverage at NYSOH on the same footing as other New York residents, and providing them with a choice.
New York policymakers moved quickly during the pandemic to suspend Medicaid requirements that could lead to unintentional disenrollment51 and to reopen the Marketplace to all eligible applicants during a special enrollment period. Given the rapid spread of coronavirus infection and the significant costs of treating the disease,52 many New York families might be interested in enrolling in off-exchange coverage now, despite the costs; moving quickly to eliminate enrollment barriers off-exchange would be an important and logical next step.
Acknowledgments
This work was supported by the New York Community Trust. Sarah Scaffidi, MSc, a research analyst at United Hospital Fund, compiled a detailed profile of immigrant characteristics in New York.
Endnotes
1. NY State of Health. February 20, 2020. NY State of Health Announces Record High Enrollment More than 4.9 Million New Yorkers Enrolled. Press Release.
2, Carrns A. October 25, 2013. Health Insurance Options Aren’t Limited to Government Exchanges. The New York Times.
3, Governor of the State of New York. April 12, 2012. Executive Order No. 42. Establishing the New York Health Benefit Exchange; statutory adoption in New York Public Health Law, Title VII.
4. New York Insurance Law section 4321.
5. New York Insurance Law Section 4328.
6. Newell P. August 2019. Mile Marker or High Water Mark? Tracking New York’s Progress in Covering the Uninsured. United Hospital Fund.
7. Only available for purchasers up to age 30, or who qualify for a hardship exemption.
8. For a description of bronze, silver, gold and platinum plans, see Standard Benefit design Cost Sharing Description Chart. April 25, 2019. New York State Department of Financial Services.
9. UHF analysis of off-exchange enrollment data provided by the New York State Department of Financial Services in personal communication, April 2019, and NYSOH enrollment data from the NYSOH Enrollment Report 2019.
10. NYSOH website.
11. Proprietary exchanges visited online on December 12, 2019 include, respectively, PolicyGenius; ehealthinsurance; and obamacare-plans.com.
12. Enrollment data from MVP Health Care New York Supplement, annual, 2018, New York State Department of Financial Services. Website for MVP Healthcare.
13. Enrollment data Excellus Blue Cross Blue Shield New York Supplement, annual, 2018, New York State Department of Financial Services. Website for Excellus Health Plans.
14. Enrollment data from Empire Blue Cross Blue Shield New York Supplement, annual, 2018. Website for Empire Blue Cross Blue Shield. With respect to declining off-exchange enrollment, representatives of Empire indicated in a personal communication in December 2019 that they had been working to shift membership to NYSOH from the off-exchange market out of concern that enrollees were missing out on available cost sharing and premium subsidies, at the suggestion of the New York State Department of Financial Services.
15. Empire BlueCross BlueShield.
16. Enrollment data from NYSOH Enrollment Report 2019; website for Fidelis Care.
17. Healthfirst enrollment from NYSOH Enrollment report 2019. Healthfirst website.
18. Healthfirst.
19. MetroPlus.
20. EmblemHealth.
21. Oscar.
22. Website for HealthPlex; website for Delta Dental; and website for Guardian Insurance.
23. Hempstead K. October 24, 2016. The Off-Exchange Individual Market and Small Group Market: New HIX Compare Data. Health Affairs Blog.
24. About 42% of NYSOH’s 271,000 qualified health plan purchasers in 2019 did not receive any financial assistance. NYSOH.
25. Affordable Care Act section 1312(f)(3). The term “lawfully present” includes U.S. citizens, naturalized citizens and immigrants with certain characteristics or at different stages of the immigrant process. For a guide to immigration status with regards to the marketplace and health coverage, see Health Coverage Crosswalk: Eligibility by Immigration Status. March 2013. Empire Justice Center.
26. New York State Department of Financial Services. November 20, 2017. Guidance Regarding the Federal Health Insurance Market Rules and NYS Insurance Law in Relation to Guaranteed Availability and Renewability.
27. 45 CFR Section 147.104. Guaranteed Availability of Coverage.
28. 26 U.S. Code Section 6055. Reporting of Health Coverage.
29. For background information on Individual Tax Identification Numbers, see https://www.irs.gov/individuals/individual-taxpayer-identification-number. Healthfirst was the only health plan identified which allows use of taxpayer identification numbers for its off-exchange applications. Policy Forms for participating off-exchange health plans were accessed through the National Association of Insurance Commissioners SERFF Filing Access, State of New York.
30. The Institute on Taxation & Economic Policy estimates that 50% to 75% of undocumented immigrants pay personal income taxes either using false Social Security numbers or Individual Tax Identification Numbers, and that undocumented immigrants in New York paid over $1 billion in state and local taxes in 2017, including about $183 million in personal income taxes. Gee LC, et al. March 2017. Undocumented Immigrants’ State & Local Tax Contributions. Institute on Taxation & Economic Policy.
31. New York State Department of Health, Documentation Checklist for Health Insurance.
32. For background information on New York City’s IDNYC program, see NYC.gov.
33. For background information on New York’s Green Light law, see DMV.
34. U.S. Internal Revenue Service. Questions and Answers on Information Reporting by Health Coverage Providers (Section 6055).
35. U.S. Internal Revenue Service. Questions and Answers about Reporting Social Security Numbers to Your Health Insurance Company.
36. U.S. Internal Revenue Service. Notice 2019-63. December 6, 2019.
37. State of New York, Executive Chamber. Executive Order No. 26. Statewide Language Access Policy. The order calls for translations in the “six most commons non-English languages spoken by individuals with limited-English proficiency in the State of New York, based on United States census data, and relevant to services offered by each such agency.”
38. Notices of Non-Discrimination are typically provided by health plans on applications or to new enrollees, and include lists of the many languages spoken, as required by Section 1557 of the Affordable Care Act. For one example of such a notice, see Healthfirst's.
39. Changes in Medicaid and CHIP Enrollment. November 2019. Medicaid and CHIP Payment Advisory Commission. Table A-2; MACSTATS: Medicaid and CHIP Data Book. December 2019. Medicare and CHIP Payment and Access Commission. Trends. Exhibit 11.
40. Artiga S, R Garfield and A Damico. September 2019. Estimated Impact of Final Public Charge Inadmissibility Rule on Immigrants and Medicaid Coverage.
41. No Stone Unturned: Strategies for Enrolling New York’s Eligible but Uninsured and Preserving Coverage Gains. October 23, 2019. Presentations available at UHF website.
42. Presentation of D. Holahan. New York’s Affordable Care Act Marketplace Now Open for Business for 2020. United Hospital Fund.
43. A.5974 (Gottfried)/S.3900 (Rivera).
44. An Economic Profile of Immigrants in New York City: First Results from NYC Opportunity Experimental Population Estimate. NYC Mayor’s Office for Economic Opportunity. 2018. Access date 10/9/2019.
45. Migration Policy Institute. Data Hub. State Immigration Data Profiles. New York. Income and Poverty.
46. Migration Policy Institute. Data Hub. Profile of the Unauthorized Population: New York.
47. Migration Policy Institute. Data Hub. County Data. Profile of the Unauthorized Population: Queens County, NY.
48. United States Citizenship and Immigrant Services, Department of Homeland Security. Inadmissibility on Public Charge Grounds. August 8, 2019. Final Rule.
49. Make the Road New York et al. against Ken Cuccinelli et al. United States District Court, Southern District of New York; State of New York, City of New York, State of Connecticut, and State of Vermont against United States Department of Homeland Security, et al. United States District Court, Southern District of New York.
50. Supreme Court of the United States. Application (19A785) granted by the Court. January 27, 2020. Department of Homeland Security et al., applicants v. New York, et al. Case numbers (19-3501); (19-3595).
51. New York State Department of Health, Office of Health Insurane Programs. April 2, 2020. General Information System. Coronavirus (COVID-19) Medicaid Eligibility Processes During Emergency Period.
52. Rae M, Claxton G, Kurani N, McDermott D, and Cox C. March 13, 2020. Potential Costs of Coronavirus Treatment for People with Employer Coverage. Peterson-Kaiser Health System Tracker. This model estimated the average costs of inpatient pneumonia admissions for patients with employer-sponsored coverage and major complications or comorbidity to be over $20,000.