Expanding Health Care Coverage

Grantee Name

Community Service Society of New York

Funding Area

Expanding Health Care Coverage

Publication Date

May 2014

Grant Amount


Grant Date:

December 2011 – November 2012

Under the Affordable Care Act (ACA), 2.2 million New Yorkers were expected to access affordable, quality health care coverage through the New York State Health Benefit Exchange, known as NY State of Health Marketplace.

Starting October 1, 2013, the Exchange would serve as a central marketplace where individuals and employers could access all public and subsidized private insurance options. The implementation of a new online system, and the influx of consumers expected to seek insurance through the Exchange, presented a high potential for errors, omissions, and conflicts. Accordingly, it was imperative to consider the consumer protections, notifications, and dispute resolution processes that would be necessary to ensure that the Exchange operate as both a consumer friendly and consumer-protective system. A well-functioning Exchange would need to provide accurate, timely, and fair determinations of eligibility and financial subsidies to ensure that all qualified individuals receive coverage.

In 2011, NYHealth awarded Community Service Society of New York (CSS) a grant to address and ensure consumer safeguards.

Outcomes and Lessons Learned

  • Reviewed national best practices for consumer protection and existing consumer safeguard mechanisms;
  • Conducted a legal analysis of existing and prospective rules governing consumer interactions and disputes both in New York and in federal guidance concerning the establishment of exchanges;
  • Held targeted interviews with key stakeholders; and
  • Produced the report “Optimizing Consumer Protections in State Health Insurance Exchanges,” which was used by the State as resource for developing the Exchange and its consumer protections.

Among the report’s key findings and actionable recommendations for policymakers:

  • Consumers should be given access to consumer support systems at every stage of the enrollment process;
  • The Exchange should maximize informal dispute resolution mechanisms and coordinate with other insurance affordability programs (Medicaid, CHIP, and Basic Health Plan) to avoid large numbers of formal appeals; and
  • The State should adopt quality assurance, monitoring, and reporting functions throughout Exchange.