Southern Tier Region $53, $82,100 54% increase 2013 to $89,800 9% increase 2014 to 2015

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1 T H E F A C T S A B O U T Taxes on New Yorkers who purchase private health insurance Estimated annual state and federal taxes and fees paid by an upstate New York business with employees Central New York Region 2013 $53, $82,100 54% increase 2013 to $89,800 9% increase 2014 to 2015 Finger Lakes Region 2013 $61, $90,600 47% increase 2013 to $98,200 8% increase 2014 to 2015 Utica/Rome/North Country Region 2013 $45, $74,300 64% increase 2013 to $82,100 10% increase 2014 to 2015 Western New York Region 2013 $50, $79,500 57% increase 2013 to $87,100 10% increase 2014 to 2015 Southern Tier Region 2013 $53, $82,100 54% increase 2013 to $89,800 9% increase 2014 to 2015 Note: Upstate New York refers to the New York counties highlighted in the map above. Shown in the map above is an estimate of state and federal taxes that an upstate New York business will pay for every $1 million in health insurance premiums. The calculations are based on tax rates set by the New York State Department of Financial Services and the New York State Department of Health in the New York state budget, the New York State Department of Health Regional Covered Lives Assessment Rates for 2014 and estimates of 2014 and 2015 federal taxes and fees mandated by the Affordable Care Act. This fact sheet illustrates how New Yorkers who have private health insurance coverage (typically through an employer) paid about $4.8 billion in state taxes for that coverage in For upstate New Yorkers, that amounts to about 5 percent to 6 percent of the premiums paid for their health insurance coverage in It also shows that health insurance taxes for upstate New Yorkers will increase by an average of 56 percent in 2014 and another 9 percent in 2015, when residents of upstate New York pay additional federal taxes and fees mandated by the Affordable Care Act CC 1 of 15

2 In 2014, upstate New Yorkers will pay about $531 million an additional 3.6 percent of their premium to cover new federal assessments. In 2015, upstate New Yorkers will pay approximately $582 million an additional 3.9 percent of their premium in federal taxes and fees. Added together, state and federal taxes will equal 7 percent to 9 percent of the total health insurance premium paid by upstate New York residents in 2014 and 8 percent to 10 percent in This report reviews the state and federal taxes paid by the privately insured for the purchase of health insurance in upstate New York and the state as a whole. New York state requires the payment of four taxes: covered lives assessment surcharge on health services assessment on insurers About this report premium tax NYS Added together, these four taxes cost the privately insured across New York state $4.8 billion in fiscal year Starting in 2014, the federal government s Affordable Care Act will collect payments of four additional taxes or fees: annual fee on health insurance providers transitional reinsurance tax for the individual market Patient-Centered Outcomes Research Institute fee risk adjustment user fee US Privately insured New Yorkers will pay an estimated $1.8 billion for these federal taxes and fees starting in In addition, New York state is expected to require payment of an exchange user fee beginning in A federal excise tax for high-cost employer-sponsored health coverage begins in Federal taxes and fees that will be implemented over the next two years will bring the total that New Yorkers statewide will pay in state and federal taxes on their private health insurance coverage to $6.6 billion in 2014 and $6.7 billion in of 15

3 State and federal taxes on New York state s privately insured: $6.6 billion (2014) and $6.7 billion (2015) Statewide, the privately insured will pay an additional $1.8 to $1.9 billion in federal taxes and fees in 2014 and 2015, respectively. The federal assessment will be layered on top of the $4.8 billion in state taxes that upstate New Yorkers paid in fiscal year Estimates of state and federal taxes and fees $8.0 NYS US $7.0 $6.0 $6.6 billion $1.8 billion $6.7 billion $97 million $1.9 billion $5.0 $4.8 billion $4.8 billion $4.8 billion Billions of dollars $4.0 $3.0 $2.0 $1.0 $0.0 New York state taxes in fiscal year Estimate of New York state and federal taxes and fees in 2014* Estimate of New York state and federal taxes and fees in 2015* New York State Taxes Sources: See methodology section. * Federal estimate based on the number of New Yorkers covered in 2012 Federal Taxes The chart above displays the state and federal tax payments made by privately insured New Yorkers: The tax payment to New York state was $4.8 billion (fiscal year ). The federal health insurance fee will add an estimated $945 million in 2014 and about $1.3 billion in In 2014 and 2015, an estimated $26 million each will be paid for the federal Patient-Centered Outcomes Research Institute fee. 2 The federal transitional reinsurance program is projected to collect $805 million in 2014 and $537 million in A portion of these funds will be used to offset the cost of individual large claims. In 2014, the state will not assess an exchange fee on the privately insured, as expenses are covered by the federal government. The executive s proposed budget allocates $54.3 million to cover the cost of the New York Health Benefit Exchange for the first quarter of 2015, funded through surplus HCRA surcharge funds. The allocation is projected to grow to $148.3 million when fully annualized with some funding from the Department of Financial Services, but most of the funding to continue to be from surplus HCRA funds. 4 3 of 15

4 New York City Bronx NYS State taxes on New Yorkers who purchase private health insurance New York state imposes four taxes on employers and individuals who purchase health insurance. The taxes include a covered lives assessment that varies by region, a surcharge (sales tax) on health services, the Section 206 assessment (formerly Section 332) on insurers and a premium tax. 1. Covered lives assessment The covered lives assessment is an annual flat surcharge (or tax) on all who are privately insured in the state. The assessment is included in the individual and family premium. The amount varies according to the region of the state in which the insured individual resides. When it was initiated in 1996, the covered lives assessment was intended to pay for graduate medical school expenses. Over time, increasing sums generated by the tax have been diverted to the state s general fund. Under the budget, New Yorkers with private health insurance paid $1.05 billion to the state for the covered lives assessment. 5 The rates to be paid by an individual and family in each of the state s eight rating regions in 2014 are shown in the map below. Covered lives assessment by New York state region for individuals and families, 2014 Utica/Watertown Rochester Individual: $8.54 Family: $28.17 Individual: $ Family: $ Jefferson Lewis St. Lawrence Hamilton Franklin Clinton Essex Northeastern Individual: $39.94 Family: $ Warren Oswego Washington Niagara Orleans Monroe Wayne Oneida Herkimer Fulton Saratoga Western Chautauqua Erie Cattaraugus Genesee Wyoming Allegany Individual: $39.40 Family: $ Central Livingston Ontario Stuben Yates Seneca Schuyler Chemung Cayuga Tompkins Onondaga Tioga Cortland Broome Individual: $55.59 Family: $ Madison Chenango Montgomery Schenectady Rensselaer Otesgo Schohaire Albany Greene Columbia Delaware Ulster Dutchess Sullivan Putnam Orange Westchester Reckland Kings Richmond Queens Nassau Long Island Individual: $61.96 Family: $ Suffolk Northern Metro Individual: $36.11 Family: $ New York City Individual: $ Family: $ Source: New York State Department of Health. Regional Covered Lives Assessment Rates of 15

5 NYS 2. Surcharge on health services A surcharge created by the state Health Care Reform Act of 1996 is collected from health plans in the form of a sales tax on certain hospital-based health services to help reimburse hospitals for losses incurred by bad debt and charity care. The surcharge applies to all members of self-insured and fully insured private commercial health insurance plans. The initial surcharge rate was 8.18 percent in 1997 and yielded $517 million. In the budget, the rate is 9.63 percent, yielding approximately $3.02 billion Assessment on insurers The Section 206 (formerly Section 332) assessment finances operations of the New York State Department of Financial Services. This assessment (.78 percent) is applied to all insurers licensed to operate in the state (i.e., life, property and casualty, and health) and is based on premiums paid in New York state. Section 206 assessments do not apply to third-party administrators, out-of-state insurers or self-funded health plans. In the budget, New Yorkers with private health insurance were expected to pay $331 million to finance the New York State Department of Financial Services Premium tax A 1.75 percent tax is applied to premiums paid by those who purchase commercial health insurance policies from for-profit health insurance companies. The revenue from these for-profit insurers goes to the state s general fund. Because the vast majority of upstate New York s privately insured are covered by nonprofit health plans, the premium tax was not included in the estimates shown with the map on page 1 of this fact sheet, or in the estimates of state taxes paid by upstate New York region on page 12. In the budget, the premium tax is projected to raise $406 million. 8 $4.8 billion in taxes on New York s privately insured, $331 million - 7% $406 million - 8% $3.02 billion - 63% $1.05 billion - 22% Surcharge on health services (9.63 percent) Premium tax on commercial health insurance from for-profit companies (1.75 percent) Covered lives assessment on all who are privately insured (rate varies by region) Section 206 assessment on insurers (.78 percent) Source: New York State Conference of Blue Cross and Blue Shield Plans based on data supplied by the New York State Department of Financial Services, New York State Department of Health, New York State Division of the Budget and the Executive Budget. 5 of 15

6 Among all business taxes levied by the state, the taxes imposed on the privately insured rank as the single largest business tax in New York state ($4.8 billion). Taxes on private health insurance coverage are the largest business taxes that any New York state employer pays $6,000 $5,000 NYS Taxes on New York state employers that offer private health insurance coverage for their employees compared to New York state business taxes, fiscal year (millions of dollars) $4,798 In the state s fiscal year, health insurance taxes were expected to contribute: $1.4 billion more than the corporate franchise tax ($3.4 billion), which is the second largest business tax. More than the next four highestranking business taxes combined ($4.4 billion bank tax, petroleum business tax, insurance taxes and corporation and utilities tax). Millions of dollars $4,000 $3,000 $2,000 $1,000 0 $847 Corporation and utilities tax $1,007 Insurance taxes* $1,162 Petroleum business tax $1,381 Bank tax $3,360 Corporate franchise tax Taxes on private health insurance Taxes on New Yorkers with private health coverage Among all of the taxes collected by New York state, taxes on private health insurance ($4.8 billion) rank third highest after personal income taxes ($40.3 billion) and sales and use taxes ($12.2 billion). Source: New York State Conference of Blue Cross and Blue Shield Plans based on data supplied by the Executive Budget Five-Year Financial Plan. Private health insurance coverage tax is based on information provided by the New York State Department of Financial Services and the New York State Department of Health. * Insurance taxes do not include an estimated $406 million collected through a 1.75 percent premium tax on commercial health insurers. The tax on commercial health insurers is included in Taxes on Private Health Insurance Coverage category in the charts on this page. FY 2013 Total (in Millions) Personal Income Tax $40,256 Sales and Use Tax $12,205 Taxes on Private Health Insurance Coverage $4,798 Corporation Franchise Tax $3,360 Cigarette and Tobacco Taxes $1,615 Bank Tax $1,381 Motor Vehicle Fees $1,380 Petroleum Business Tax $1,162 Estate Tax $1,127 Insurance Taxes* $1,007 Corporation and Utilities Tax $847 Real Estate Transfer Tax $660 Motor Fuel Tax $515 Alcoholic Beverage Taxes $241 Highway Use Tax $147 Auto Rental Tax $109 Alcoholic Beverage Control License Fees $51 Pari-mutuel Taxes $16 Other Taxes $1 Real Property Gains Tax <$1 6 of 15

7 $3,500 NYS Trends in New York state taxes on the privately insured Trends in the covered lives assessment and surcharge on health services, 1997 through 2013 (millions of dollars) $3,000 $2,743 $2,711 $3,016 $2,500 $2,000 $1,710 $1,900 $2,054 $2,240 $2,330 $1,500 $1,000 $500 $665 $517 $665 $535 $690 $568 $690 $611 $670 $631 $690 $707 $690 $836 $703 $1,060 $737 $1,400 $775 $850 $920 $1,160 $1,160 $1,021 $1,018 $1,045 $ Post DRP* Covered lives assessment Surcharge on health services Source: New York State Conference of Blue Cross and Blue Shield Plans based on data supplied by the New York State Enacted Budget Financial Plans and Executive Budget Five-Year Financial Plan. *In February 2009, New York state adopted the Deficit Reduction Plan to close the state s deficit of $1.6 billion. More than $400 million in added taxes to the privately insured was a part of the Deficit Reduction Plan, which included $240 million in added covered lives assessments implemented in two phases: $120 million went into effect retroactively to January 1, 2009, and $120 million effective April 1, Since 1997, the HCRA surcharge on health services has increased by 483 percent, and the covered lives assessment has increased by 57 percent. Combined revenues from the covered lives assessment and the surcharge on health services rose from $1.2 billion to $4.1 billion (from fiscal year to fiscal year ). 7 of 15

8 NYS Trends in the Section 206 insurance assessment, 1997 through 2012 (millions of dollars) $500 $450 $435 $442 $439 $411 $416 $400 $350 Millions of dollars $300 $250 $200 $178 $150 $100 $97 $50 $ projected 2012 projected Source: New York State Conference of Blue Cross and Blue Shield Plans based on data supplied by the New York State Department of Financial Services, Oct Since inception of the New York State Department of Financial Services Section 206 assessment (formerly Section 332) in 1997, the tax on insurers has increased by 329 percent. The chart above includes the tax on all insurers. 8 of 15

9 US New federal taxes and fees on New Yorkers resulting from the Affordable Care Act Upstate New York In 2014, the Affordable Care Act is expected to increase health care premiums paid by upstate New York s privately insured by $531 million. The estimated additional 3.6 percent tax burden on upstate New Yorkers is based on national analyses of the impact of a new federal health insurance fee (2.2 percent), a federal transitional reinsurance tax (1.4 percent) and the federal Patient-Centered Outcomes Research Institute tax (about.04 percent). In 2015, the upstate New York tax burden on health insurance premiums will be 3.9 percent, due to a built-in increase in the federal health insurance fee (to 3.0 percent), more than offsetting a decrease in the transitional reinsurance fee (to 0.9 percent). In addition, privately insured small groups and individuals may be expected to cover all or a portion of the costs of operating New York s health benefit exchange, projected to be almost $97 million in New York state Statewide, the privately insured will pay an estimated $1.8 to $1.9 billion in federal taxes and fees in 2014 and 2015 respectively. The federal assessment will be layered on top of the $4.8 billion in state taxes that New Yorkers were paid in fiscal year $1.8 billion to $1.9 billion in federal taxes on New York state s privately insured in 2014 and $26 million - 2% $26 million - 1% $805 million - 45% $945 million - 53% $537 million - 29% $1.3 billion - 70% Patient-Centered Outcomes Research Institute Tax (.06%) Transitional reinsurance tax (1.9%) Health insurance provider fee (2.2%) Source: See Methodology section Patient-Centered Outcomes Research Institute Tax (.06%) Transitional reinsurance tax (1.2%) Health insurance provider fee (3.0%) New York s privately insured will pay additional federal taxes and fees beginning in 2014: The annual fee on health insurance providers will add $945 million in 2014 and $1.3 billion in The transitional reinsurance tax is based on a $63 national per capita amount in When applied, it will add $805 million in 2014 and $537 million in 2015 to premiums in the individual market (based on an estimated per capita amount for 2015). To support the Patient-Centered Outcomes Research Institute, health plans will pay an estimated $26 million each in 2014 and of 15

10 Federal taxes included in the 2010 health care reform law The following six federal taxes and fees are included in the 2010 Affordable Care Act: Annual fee on health insurance providers 10 Beginning in 2014, this fee will be based on each health insurance company s market share of net premiums written, adjusted for size and corporate structure. The tax will be assessed directly on all fully insured health plans and indirectly on their customer base. 11 Nationally, the Affordable Care Act requires payment of $8 billion in 2014, $11.3 billion each in 2015 and 2016, $13.9 billion in 2017 and $14.3 billion in After 2018, the tax is expected to collect $14.3 billion, indexed to the rate of growth in premiums. Each year, the calculation will be based on the market share of each assessed plan and will change based on the number of companies in the insured market. Under this tax provision, a health plan could incur financial losses but would still be subject to the market share tax. Transitional reinsurance program for the individual market. 12 Federal law created a temporary reinsurance program that nationwide is expected to collect $10 billion in 2014, $6 billion in 2015 and $4 billion in 2016 from health insurance carriers and self-funded plans. Additionally, a separate contribution totaling $2 billion in 2014, $2 billion in 2015 and $1 billion in 2016 is to be deposited into the U.S. Treasury. All insurers and self-insured group health plans are required to contribute on behalf of all group health plans and health insurance coverage they provide. About 80 percent of the contributed fees will reinsure the allowed costs for high-risk individuals. The remaining funds will go into the general fund of the U.S. Treasury. Exchange user fee (for individual and small group coverage only) 13 Health insurance plans will be charged a fee to participate in the health insurance exchange. New York state is not assessing the fee in 2014 and has not yet determined how it will be charged in succeeding years. However, as the exchange is required by federal law to become self-supporting, it is expected that a charge could be initiated in Patient-Centered Outcomes Research Institute fee 14 The Patient-Centered Outcomes Research Institute fee, also known as the Comparative Effectiveness Research fee, is a fee paid to the federal government to fund research that will drive improvements to health care delivery and decision-making. The fee is assessed per covered life (subscribers and beneficiaries): $1 for policy and plan years ending between Oct. 1, 2012, and Oct. 1, $2 for policy and plan years ending between Oct. 1, 2013, and Oct. 1, US To be determined for policy and plan years ending after Oct. 1, 2014, based on the projected health care inflation rate. 10 of 15

11 US Risk adjustment user fee (for individual and small group coverage) 15 This federal program was established to maintain the stability of the consumer and small business health insurance markets. Unlike the reinsurance program, the risk adjustment program is permanent. The fee will cover the program s administrative expenses. The fee is $0.96 per enrollee per year. New York state will initially follow the federal risk adjustment program, but has expressed an intention to operate its own risk adjustment program in the future. It will be necessary to identify an ongoing source of revenue to administer the program. 16 Excise tax on high-cost employer-sponsored health coverage in An additional tax known as the Cadillac tax is projected to be assessed in Insurers and administrators of employer-sponsored health insurance plans will pay a 40 percent excise tax on health coverage that is beyond certain levels. The tax is projected to increase federal revenues by $108 billion over the period. The estimated increase consists of about $31 billion in excise tax receipts and about $77 billion in higher net revenues from the associated effects of changes in employees taxable compensation. 18 This tax will be paid on premiums that exceed the established dollar limits of $10,200 for single coverage and $27,500 for family coverage in The threshold amounts increase for retirees ages 55 to 64 and workers in high-risk professions to $11,850 for singles and $30,950 for families. Later years will be indexed to the cost of living plus 1 percent. The effect of the excise tax is difficult to determine at this time, because it is dependent on the nature and cost of insurance offered by employers in of 15

12 NYS Estimated annual tax rates per $100 in paid health insurance premiums in upstate New York, based on actual state rates and estimated federal rates in 2014 US Region Covered lives assessment* NEW YORK STATE FEDERAL TOTAL Surcharge on health services** Assessment on insurers** 2014 Health insurance provider fee Reinsurance fee Patient- Centered Outcomes Research Institute fee Total NYS and US Finger Lakes $1.76 $3.60 $0.78 $2.20 $0.67 $0.03 $9.04 Central New York $0.93 $3.60 $0.78 $2.20 $0.67 $0.03 $8.21 Southern Tier $0.93 $3.60 $0.78 $2.20 $0.67 $0.03 $8.21 Utica/Rome/North Country $0.14 $3.60 $0.78 $2.20 $0.67 $0.03 $7.42 Western New York $0.65 $3.60 $0.78 $2.20 $0.67 $0.03 $7.93 Source: See methodology section Note: Counties are assigned to upstate New York regions based on the New York state Covered Lives Assessment regions *2014 rates ** rates 12 of 15

13 NYS Worksheet for businesses to estimate state and federal taxes and fees in New York state An upstate New York employer can use this tool to estimate the employer s share of state and federal taxes and fees required to provide health insurance to employees. For every $100 an employer pays in premium, the employer pays an amount for the state covered lives assessment, surcharge on health services, Section 206 assessment on insurers, the federal health insurance provider fee, reinsurance fee and Patient-Centered Outcomes Research Institute fee as shown in the chart above. In addition, small group employers would be assessed a risk adjustment fee. US 2014 Sample for a Central New York business Step 1 - Determine your premium for the year $1,000,000 Step 2 - Divide step 1 by 100 $10,000 (to use the chart above) Step 3 - Multiply step 2 by the covered lives $9,300 assessment for your region Step 4 - Multiply step 2 by the surcharge on $36,000 health services Step 5 - Multiply step 2 by the assessment $7,800 on insurers Step 6 - Multiply step 2 by the tax on health $22,000 insurance Step 7 - Multiply step 2 by the reinsurance fee $6,700 Step 8 - Multiply step 2 by the Patient Centered $300 Outcomes Research Institute fee Step 9 - Add steps 3-8 $82,100 This is the total tax to be paid to the state and federal governments Your estimate year In this example, a Central New York business with yearly premiums of $1 million for health insurance coverage for its employees would have included in those premiums state and federal taxes and fees of $82,100 in of 15

14 Methodology Impact of state taxes on upstate New York premiums Upstate New York premiums used to calculate the impact of state taxes were based on regional upstate New York premium averages reported in the 2010 Milliman Group Survey, a subscriptionbased service that takes identical benefit designs to create comparable prices among health plans within regions and among states throughout the nation. These numbers were adjusted to 2013 through 2015 dollars using the 2011 Milliman Medical Index for 2011: 2012 Milliman Medical Index for 2012, and the 2013 Milliman Medical Index for each remaining year. Using the assumption that a group includes 54 percent single policies and 46 percent family policies, the impact of the covered lives tax was based on county of residence and state-set annual assessments for single policies and family policies. The 2015 covered lives tax rates are calculated by adjusting the 2014 state-set assessments to 2015 using the 2013 Milliman Medical Index trend. The impact of the 9.63 percent surcharge on hospital-related services assumed a medical benefits loss ratio of 85 percent, of which 44 percent of medical benefits were for hospital-related services. The Section 206 (formerly Section 332) assessment on insurers was based on an estimated.78 percent of premium assumption. These assumptions were used to estimate the tax for every $100 in premiums paid. Based on the health policies commonly sold to medium-sized groups in upstate New York, the illustrated $1 million in premiums would pay for the health insurance coverage of a workforce that ranges in size from employees. Estimate of impact of federal health insurance fee on New York state premiums Three estimates of the range of impact of the health insurance fee on premiums were used to arrive at an average impact of 2.2 percent in 2014 and 3.0 percent in The Oliver Wyman firm in Nov estimated the impact in the first year of the tax (2014) as ranging from a conservative 1.9 percent to an estimate considering greater self-funding in the market of 2.3 percent. The firm s 2015 estimate indicated a range of 2.6 percent to 3.2 percent. 19 The Joint Committee on Taxation estimated the impact in 2014 as ranging from 2.0 percent to 2.5 percent. 20 A Milliman Research Report in April 2013 estimated the premium increase due to the health insurer fee as approximately 1.7 percent to 2.4 percent in 2014, and 2.1 to 3.0 percent in The projected impact was applied to the insured premium of $42.9 billion reported on the 2012 Health Blank Annual Statement submitted by health insurance providers to the New York State Department of Financial Services to calculate the impact of the federal health insurance fee if it had been in place in Estimate of impact of federal transitional reinsurance program on New York state premiums The federal Department of Health and Human Services requires that all insurers and self-insured group health plans contribute $63 yearly per enrolled member during This rate was applied to the total insured premium of $42.9 billion and total reported membership of 12.8 million obtained from the New York State 2012 Health Blank Annual Statements to determine that 1.9 percent of premium would have been paid to the federal government if the program was in place in This fee is estimated to decline to 1.2 percent in 2015 as the aggregate amount of reinsurance fee is reduced according to the Affordable Care Act. The estimate is based on insured business only, as data is not available to estimate the tax on selffunded business. Estimate of impact of Patient-Centered Outcomes Research Institute fee on New York state premiums The Patient-Centered Outcomes Research Institute fee for 2014 and 2015 is determined at the rate of $2 per member per year, applied to the total insured premium of $42.9 billion and total reported insured membership of 12.8 million obtained from the New York State 2012 Health Blank Annual Statements. 14 of 15

15 Endnotes 1 Starting in 2014, the tax will be assessed on all fully insured health plans, individuals purchasing coverage on their own, Medicare beneficiaries enrolled in a Medicare Advantage plan or a prescription drug plan and on states that contract with health plans for Medicaid. 2 Grossman, E., et. al., Office of the Legislative Counsel. Compilation of Patient Protection and Affordable Care Act. May Section 1183, page 679. Web 7 March Department of Health and Human Services. Federal Register. Vol. 77, No Dec. 7, To be codified at 45 CFR Part 153, 155, 156, 157 and 158. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for Page Web 3 July Web 7 March Building on Success, Executive Budget. Jan 21, Page 42. Web 7 March New York State Department of Health. Regional Covered Lives Assessment Rates Web 7 March New York State Conference of Blue Cross and Blue Shield Plans, based on data supplied by the New York State Department of Financial Services, New York State Department of Health, New York State Division of the Budget and the Executive Budget. 7 New York State Conference of Blue Cross and Blue Shield Plans. 8 New York State Conference of Blue Cross and Blue Shield Plans. 9 New York Health Benefit Exchange. 10 Grossman, Section 9010, page The fee is not assessed on self-insured health plans or federal, state or other government plans. Tax-exempt insurance providers will only pay the tax on 50 percent of their net premiums. Voluntary employee benefit associations and nonprofit plans that receive more than 80 percent of revenue from government programs for income, older adults or people with disabilities covered by programs such as Medicaid, Medicare and the Child Health Plus insurance plan are not subject to the fee. 12 Grossman, Section 1341, page Grossman, Section 1311, page Grossman, Section 1183, page Department of Health and Human Services. Federal Register. Vol. 78 No. 47. March 11, page Web 7 March Winkelman, R. and Mehmud, S. Risk Adjustment and Reinsurance under the ACA New York State Recommendations. June page 22. Web 7 March Grossman, Section 9010, page Congressional Budget Office. The Budget and Economic Outlook: Feb page 111. Web 7 March Carlson, C. Annual Tax on Insurers Allocated by State. Nov. 2012, page 4. Web 7 March Barthold, T. Joint Committee on Taxation. Letter to Senator Jon Kyl. Oliver Wyman. June 3, Web 7 March Doucet, M and Yahnke, J. ACA health insurer fee: Estimated impact on the U.S. health insurance industry. April 2013, page 3. Web 7 March The filings may be somewhat inflated, because some coverage is split in New York City for municipal employees (one carrier has hospital coverage, one has medical, another has drug, etc.), so the same member may be counted multiple times. It is not possible to adjust for this over-counting, although in the context of New York state enrollment, it should not have a great impact. 23 Department of Health and Human Services. Federal Register. Vol. 77, No Page of 15