Healthcare in New York refers to allhealth care available in the state ofNew York. The healthcare system does not provide for the entire population, but instead most people are covered by a combination of private insurance and various federal and state programs. The state relies on acounty-based system for delivery of public health services, though thestate government handles many things in areas such as professional and facility licensing. Services can broadly be categorized intoinpatient care,outpatient care, andlong-term care. The health care and social assistance sector accounted for 18.2% of total non-farm employment in the state.[1]
The US health system does not provide health care to the country's entire population.[2] Instead, most citizens are covered by a combination of private insurance and various federal and state programs.[3] Health insurance was most commonly acquired through a group plan tied to an employer.[4] Public payers (Medicare +Medicaid + other government programs) account for a majority of all health care funding. 44% of the state population and 60% of New York City were enrolled in Medicaid or the Essential Plan as of September 2024.[5] 72% of hospital inpatient admissions, 62% of hospital outpatient care, and 53 % of hospital patient service revenue was covered by Medicare or Medicaid.[6]
Essential health benefits (EHBs) are required for non-grandfathered individual and small group plans, meant to reflect benefits typically included in largeemployer-sponsored plans, but are not state-mandated for fully-insured large employer plans and do not apply to self-insuredERISA (often large employer) plans.[7][8] Since a majority of New Yorkers are enrolled in self-insured ERISA plans, EHBs cover a small minority of New Yorkers.[citation needed] There are no minimum coverage standards fordental plans, and routine adult dental services are not considered EHBs.[9][10] New York has enacted additional mandates that exceed federal EHB requirements, for exampleTimothy's Law requires that all fully-insured plans provide comparable coverage for mental health services as they do for physical health services to ensure mental health parity, including forsubstance use disorders.[11][12] Self-insuredERISA plans are exempt from state insurance mandates due to federal preemption but are subject to federal requirements like theMental Health Parity and Addiction Equity Act.[13]
Health insurance claim appeals are governed by theAffordable Care Act's federal claims and appeals and external review requirements in all cases, with fully insured plans implementing those rights through New York's state-run grievance and external appeal system, while self-fundedERISA plans implement the same federal standards through ERISA-based internal appeals and a federal external review process not administered by the state.[14][15][16] The vast majority of external appeals are over themedical necessity of treatment.[17]
NY State of Health is thehealth insurance marketplace that manages eligibility and enrollment forMedicaid applicants and selects the benchmark plan for EHBs.[18][19][20][21] New York has transitioned toMedicaid managed care (MMC) forprimary andacute care, away from thefee-for-service model, and most beneficiaries enroll in "mainstream" Medicaid managed care plans.[22][23][24] Managed long-term care (MLTC) plans coverlong-term services and supports, with "partial capitation" plans covering only certain Medicaid services being the most familiar and having the most enrollment, and "full capitation"Medicaid Advantage Plus (MAP) andProgram of All-Inclusive Care for the Elderly (PACE) plans combining allMedicare and Medicaid services.[25] The Medicaid behavioral health system has also transitioned to MMC.[26]
The Essential Plan offers essential health benefits for non-Medicaid-eligible residents with up to 250% offederal poverty level incomes with minimal or $0 monthly premiums and nominal or $0copays.[27][28] It is the state implementation of theAffordable Care Act Basic Health Program. Its benefits include (but are not limited to) dental, vision, inpatient and outpatient hospital care, prescription drugs, and free preventive care like routine exams and screenings.[27]
TheCenters for Disease Control and Prevention describes the public health infrastructure as three components:workforce capacity and competency: the recruitment, continuing education, and retention of health professionals;organizational capacity: the consortium of public health agencies and laboratories, working with private and nonprofit organizations; andinformation and data systems: the up-to-date guidelines, recommendations and health alerts, and the information and systems that monitor disease and enable efficient communication.[29]
New York State relies on a county-based system for delivery of public health services.[31] The stateDepartment of Health promotes the prevention and control of disease, environmental health, healthy lifestyles, and emergency preparedness and response; supervises local health boards; oversees reporting and vital records; conducts surveillance of hospitals; does research at theWadsworth Center; and administers several other health insurance programs and institutions.[31] 58 local health departments offer core services including assessing community health, disease control and prevention, family health, and health education; 37 localities provide environmental health services, while the other 21 rely on the state Department of Health.[31]
At the local level, public health workers are found not only in local health agencies but also in private and nonprofit organizations concerned with the public's health.[29] The most common professional disciplines are physicians, nurses, environmental specialists, laboratorians, health educators, disease investigators, outreach workers, and managers, as well as otherallied health professions.[29] Nurses represented 22% of the localities' workforce (and 42% offull-time equivalent workers in rural localities), scientific/investigative staff represented 22%–27% of the workforce, support staff represented 28%, education/outreach staff represented 10%, and physicians represented 1%.[31]
Providers are paid through a combination of administratively defined public payment systems and privately negotiated commercial rates, supported by internalfee-for-service accounting. Payment mechanisms vary by payer and provider type, and are largely independent of providers' internal list prices. Most institutional providers maintainchargemasters—comprehensive internal lists of billable services, procedures, and supplies with associated nominal prices—that support billing operations, accounting, regulatory reporting, and contract negotiations, but function primarily as internal reference tools rather than actual payment amounts.[32]
Commercial insurance payments are determined through contracts negotiated between insurers and provider organizations.[33] Inpatient hospital services are most commonly reimbursed usingDRG-based case rates, butper diem rates andpercentage-of-charges arrangements are also used, sometimes concurrently within the same insurer or hospital contract. Outpatient services use a mix of case rates, percentage-of-charges, and fee schedules that vary by service category. As a result, payment levels differ across insurers, providers, and regions.
Medicare and New York Medicaid reimburse providers through administratively defined methodologies.Acute hospitalinpatient services are paid usingDRG-based case payments, under theIPPS for Medicare and the3M All Patient Refined DRG (APR-DRG) for Medicaid.[34][35][36] For outpatient hospital services, Medicare uses theOPPS while Medicaid generally usesambulatory patient groups (APGs).[37][38] Physician and other professional services are generally reimbursed under fee schedules.
To help offset financial losses from serving Medicaid and uninsured patients,disproportionate share hospital (DSH) payments are distributed through multiple mechanisms.[39][40] These include theHealth Care Reform Act (HCRA)-funded Indigent Care Pool and adjustments for hospitals, DSH intergovernmental transfers for public hospitals, and DSH payments to Institutes for Mental Disease (IMDs). The Indigent Care Pool (ICP) is intended to help cover hospitals' costs from providingcharity care and from unpaid bills classified asbad debt, in addition to their Medicaid shortfalls.[41][42] Hospitals receive ICP reimbursements for debt even as they collect the same debt from patients, since nothing in the law requires them to credit patient accounts.[43] As of 2018, hospitals received about $1.1 billion per year in ICP funds.[40][42]
State directed payments (SDPs) allow states to require Medicaid managed care plans to pay providers at specific rates or using defined methods — such as uniform payment increases, minimum fee schedules, or value-based payment models — in addition to the base payment rates negotiated between plans and providers.[44][45] New York's Directed Payment Template programs (DPTs) includevalue-based payment initiatives such as population-based payments forpatient-centered medical home providers.[46] They also include enhanced reimbursements forsafety net,critical access, and sole community facilities, as well as forNYC Health + Hospitals' outpatient services.[47][48][49][50][51] These payments are delivered through highercapitation rates paid to managed care plans, with the nonfederal share financed by state general funds,HCRA provider taxes, and intergovernmental transfers.
Ageneral hospital is a standardacute care hospital with inpatient beds and24/7 physician coverage.[52] Aninpatient rehabilitation facility (IRF) is devoted to the rehabilitation of patients following stabilization of their acute medical issues.
In the continuum ofsubstance use disorder treatment programs,ASAM-aligned levels of care includes inpatient services (ASAM levels 3.7–4).[53]
New York operates a dual system of inpatientpsychiatric care. State psychiatric centers are publicly operated hospitals run by theOffice of Mental Health (OMH) and primarily serve individuals withserious mental illness who require extended inpatient treatment, forensic patients involved with the criminal justice system, or individuals civilly committed.[54] Private psychiatric hospitals provide inpatient psychiatric care, but their role has declined over time as psychiatric care shifted toward community-based and general-hospital settings.[55] General hospitals may operate apsychiatric inpatient unit, and while the physical plant and hospital operations are licensed as Article 28 hospitals, the psychiatric services themselves are separately licensed and regulated by OMH.[56]
Anintermediate care facility for individuals with intellectual disabilities (ICF/IID) is aMedicaid-funded institution for people withintellectual disabilities anddevelopmental disabilities regulated by the stateOffice for People With Developmental Disabilities (OPWDD).[57][58] They are institutional and require active treatment services.[59]
The American Hospital Directory lists 261 active hospitals in New York State in 2022. Two hundred and ten of these hospitals have staffed-beds with a total of 64,515 beds. The largest number of hospitals are in New York City.[60] The January 1, 2022 listing by the state Department of Health of general hospitals covered by theNew York Health Care Reform Act show 165 hospitals 63 closed hospitals, and 51 hospitals that had been merged with other hospitals.[61] The oldest hospital in New York State and also oldest hospital in the United States is theBellevue Hospital in Manhattan, established in 1736. The hospital with the largest number of staffed beds is theNewYork-Presbyterian Hospital in Manhattan with 2,678 beds in its hospital complex.
Ahospital-based outpatient department (HOPD) is an outpatient site operated under a hospital's Article 28 operating certificate.[62]Diagnostic and treatment centers (D&TCs) are freestanding Article 28 facilities, hospital-affiliated or independent, providing outpatient services but having no inpatient beds.[63] Anextension clinic is an off-site component of a general hospital or diagnostic and treatment center outpatient program.[64] HOPDs and freestanding D&TCs are both reimbursed by Medicaid underambulatory patient groups (APGs), but HOPDs are treated as part of the hospital for cost reporting and supplemental payments and therefore have higher effective facility costs and reimbursement, while under Medicare, HOPDs are paid underOPPS and D&TC services are generally paid under the physician fee schedule.
In the continuum ofsubstance use disorder treatment programs,ASAM-aligned levels of care includes outpatient services (ASAM levels 1–2.5).[53] Anoutpatient program provides the baseline outpatient services, e.g. counseling and case management.[65]Outpatient rehabilitation services are designed to assist with more chronic conditions and are typically scheduled three to five days per week for at least two hours per day.[66]Opioid treatment programs are specialized outpatient services that administer and monitor addiction medications like methadone or buprenorphine under strict medical protocols.[67]
As morepsychiatric emergencies are being pushed into emergency departments, many patients are "boarded" (held after a decision to admit/transfer) for hours to days.[68]Comprehensive psychiatric emergency programs (CPEPs) are meant to provide a single entry point for psychiatric emergencies, including crisis intervention in an emergency room setting, mobile crisis outreach, crisis residence beds, extended observation beds (up to 72 hours), and triage/referral.[69][70]
The stateOffice of Mental Health (OMH) licenses a wide range of outpatient and rehabilitative programs designed to support individuals with serious mental illness in the community.[71]Assertive Community Treatment (ACT) teams provide intensive, multidisciplinary, 24/7 community-based services for individuals with severe mental illness who have difficulty engaging in traditional outpatient care.[72] Additional programs include partial hospitalization, continuing day treatment, and intensive outpatient services.[73]
Aresidential health care facility (RHCF) is anursing home, i.e. facilities providing medical,residential care to adults who are substantially unable to live independently, with clinical-level staffing and oversight.[74] RHCFs are mostly funded throughMedicaid.[75]
Anadult care facility (ACF) is a facility providing non-medical, residential care to adults who are substantially unable to live independently.[76][77][78] ACFs are legally prohibited from retaining residents who need ongoing medical or nursing care.[79] ACFs are mostly funded throughSupplemental Security Income (SSI) andstate supplementary payments (SSP).[80] They are regulated underArticle 7 of theSocial Services Law andTitle 18 (Social Services) of theNYCRR.
Anadult home is a type of ACF that provides non-medical, residential care—including room, board, personal care, and supervision—to five or more adults who are not related to the operator.[76][77] Adult homes are regulated by theDepartment of Health.[81] Atransitional adult home, sometimes referred to as animpacted adult home, is an adult home with a capacity of at least 80 beds where at least 25% of residents have aserious mental illness (SMI).[82][83] Anassisted living residence (ALR) is a licensure category created in 2004 to standardize the use of the term "assisted living" and establish consumer protections.[84] Anassisted living program (ALP), established earlier underMedicaid waivers, enable ACF residents to receive Medicaid-funded home care services.[85] Facilities with at least 55% ALP beds are excluded fromJustice Center oversight, much likenursing homes, but are otherwise little different from regular adult homes.[86][87] Many facilities operate both ALRs and ALPs concurrently.
Afamily type home is a type of ACF that provides non-medical, residential care to four or fewer adults.[88] Family-type homes are regulated by the stateOffice of Children and Family Services.[81]
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In the continuum ofsubstance use disorder treatment programs,ASAM-aligned levels of care includes residential services (ASAM levels 3.1–3.5).[53]Residential services are24/7 services in a residential setting.[89]Stabilization services are structured, medically supported, short-term residential services to achieve medical/psychosocial stabilization.[89]Rehabilitation services are structured, longer-term residential services for individuals with functional impairments needing habilitative supports.[89]Reintegration services are focused on supporting return to community living, often in less structured environments.[89]
The stateOffice for People With Developmental Disabilities (OPWDD) oversees a network of certified residential programs underMedicaid home and community-based services waivers (HCBS waivers) for individuals with developmental disabilities who require long-term housing with supervision and habilitative supports. Acommunity residence (CR) provides housing, supplies and services, supportive interpersonal relationships, supervision, and training assistance;supervised CRs with staffing available around the clock, andsupportive CRs for more independent routines and variable support.[90] Anindividualized residential alternative (IRA) is a type of CR with more emphasis on independent living;supervised IRAs with staffing available around the clock, andsupportive IRAs with staff support delivered as needed.[90] Afamily care home is a private home with trained caregivers.[91]
Alicensed home care services agency (LHCSA) provides medical, non-residential (community-based)home care services that provide skilled nursing, home health aide services, personal care, and other supportive services in a patient's residence.[92] Acertified home health agency (CHHA) provides home care services and isMedicare-certified.[92] The Consumer Directed Personal Assistance Program (CDPAP) also covers personal care services, providing non-medical assistance withactivities of daily living (ADLs) and allowing recipients to direct unlicensed caregivers such as relatives.[93] CDPAP and LHCSAs are mostly funded throughMedicaid, while CHHAs are mostly funded through Medicare with Medicaid as a secondary payer.
Anadult day health care (ADHC) is anadult daycare center providing medical, non-residential (community-based) care to functionally impaired adults in a professionally staffed, group setting.[94] Asocial adult day care (SADC) is an adult daycare center providing non-medical, non-residential (community-based) care to functionally impaired adults.[95] Both are regulated by theDepartment of Health, while SADCs are also regulated by the stateOffice for the Aging. They are mostly funded throughMedicaid.
The stateOffice of Mental Health (OMH) licenses a wide range of outpatient and rehabilitative programs designed to support individuals with serious mental illness in the community.[71]Personalized Recovery Oriented Services (PROS) programs combine treatment, rehabilitation, and support services to promote recovery, employment, and community integration.[96] Additional programs include supportive housing linked to mental health services.[73]
OPWDD also certifies a broad range of non-residential day and community-based programs that provide ongoing supports underHCBS waivers. These includeday habilitation services focused on life skills and socialization;community habilitation services delivered in integrated community settings;prevocational services that build work readiness; andsupported employment services (SEMP) that assist individuals in obtaining and maintaining competitive or customized employment.[97]
Licensedpharmacists with a certificate of administration, and certified pharmacy interns under certified pharmacist supervision, can administer vaccines underphysician or nurse practitioner prescriptions or standing orders.[98][99][100][101]Nurse practitioners can issue prescriptions or standing orders to pharmacists, and standing orders toregistered nurses to execute.[102] Certified pharmacists may immunize adults against influenza, pneumococcal, zoster, hepatitis A/B, HPV, MMR, varicella, COVID-19, meningococcal, tetanus/diphtheria/pertussis, and additionalACIP-recommended immunizations authorized by the commissioner, and may immunize minors (ages 2–17) only against influenza.[100] In September 2025, the governor issued anexecutive order temporarily authorizing pharmacists to prescribe and administer COVID-19 vaccines, and physicians or nurse practitioners to prescribe and issue standing orders, for patients aged 3 and older.[103]
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The stateEducation Department coordinatesprofessional licensing for health professions. ItsState Board for Medicine advises theBoard of Regents on licensing, practice standards, and professional conduct for physicians and physician assistants.[104] TheState Board for Nursing advises on licensing, professional practice, education standards, and conduct forlicensed practical nurses,registered professional nurses,nurse practitioners, andclinical nurse specialists.[105]
New York fundsgraduate medical education (GME) through theDepartment of Health with hospital rate add-ons,HCRA-based GME and professional education pool supplemental payments, and administering programs like Empire Clinical Research Investigator Program (ECRIP) and Doctors Across New York (DANY).[106][107][108][109] New York accounted for nearly half of the nation's total state Medicaid GME spending—$1.82 billion of the total $3.87 billion in 2012—and more than 10 times any other state.[110]
The Statewide Health Information Network for New York (SHIN-NY, pronounced "shiny") is the statehealth information exchange that allows healthcare providers to access and share patient data, and includes severalregional health information organizations such asHixny.
New York City is the largest city in the United States and offers all available health care services.[111]
Buffalo is the second largest city in the State of New York.
This article incorporates text from this source, which is in thepublic domain.