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Download the NY Health Exchange Guide
Under the Affordable Care Act’s regulations, each state is required to have a health insurance exchange, either operated by the state or by the federal government as well as quasi state/federal government run exchanges. New York State opted to establish and operate its own exchange.
Since October 2013, customers have been able to shop for and compare different health insurance plans from a variety of insurers through the online marketplace.
These health insurance plans from New York State of Health are available right here through Vista Health Solutions for you to explore and purchase (as well as non health insurance marketplace plans).
Please take the time to explore our FAQs about the Affordable Care Act, and a brief history of health insurance in New York State.
Individuals: What you need to know about the Affordable Care Act
1. You are required to have health insurance
Every citizen and permanent United States resident needs to have health insurance or they face paying a penalty. This can be insurance through your place of employment, insurance from your spouse’s workplace, a plan purchased at the state health insurance exchange, or coverage through a government assistance program like Medicare or Medicaid.
The penalty for not having health insurance in 2014 will be $95 for individuals or 1 percent of your income, whichever is greater. In 2015 that penalty increases to $325 or 2 percent of income, and in 2016 it goes up again to $695 or 2.5 percent of taxable income. After 2016, the penalty increase will be tied in annually to the cost of living adjustment.
2. The four levels of insurance plans to chose from at the New York Health Benefits Exchange
At the New York Health Benefits Exchange, you have the option to choose from four tiers of health insurance plans:
- Bronze level – 60 percent coverage
- Silver level – 70 percent coverage
- Gold level – 80 percent coverage
- Platinum level – 90 percent coverage
Each level offers different premiums covering different levels of medical expenses. For example, the Bronze level plans has a lower premium than the Silver level plans, but the Bronze plans has higher out of pocket costs. The consumer makes up for those other costs through deductibles, co-pays, and/or coinsurance.
For each tier there is a limit on out-of-pocket spending that’s equal to the Health Savings Account (HSA) current law limit ($3,250 for an individual and$6,450 for a family in 2014).
If your annual income falls somewhere between 100 and 400 percent of the federal poverty line, then there will be an even lower cap on out of pocket expenses.
For example, if your income is:
- 100-200% FPL: one-third of the HSA limits ($1,983/individual and $3,967/family);
- 200-300% FPL: one-half of the HSA limits ($2,975/individual and $5,950/family);
- 300-400% FPL: two-thirds of the HSA limits ($3,987/individual and $7,973/family).
3. You might qualify for a tax credit
Depending on your income level, you might qualify for a tax credit when purchasing health insurance at the exchange. Those with annual incomes between 133 and 400 percent of the Federal Poverty Line (FPL) will have their premium contributions capped at a maximum of 9.5 percent of their income when purchasing a Silver level plan.
For example, if your income is:
- Up to 133 percent of the FPL = your maximum premium contribution will be 2 percent of your annual income
- 133-150 percent of the FPL = your maximum premium contribution will be 3 – 4 percent of your annual income
- 150-200 percent of the FPL = your maximum premium contribution will be 4 – 6.3 percent of your annual income
- 200-250 percent of the FPL = your maximum premium contribution will be 6.3 – 8.05 percent of your annual income
- 250-300 percent of the FPL = your maximum premium contribution will be 8.05 – 9.5 percent of your annual income
- 300-400 percent of the FPL = your maximum premium contribution will be 9.5 percent of your annual income
Individuals in the 133 to 400 percent of FPL range are also eligible for a premium tax credit. The premium tax credit is determined by subtracting the difference between the individual’s maximum premium contribution and the unsubsidized cost of the second lowest Silver level plan offered in an individual’s geographic area. That amount is their premium tax credit.
Let’s take a look at an example:
John is a 29-year-old individual earning $30,000 a year and he wants to purchase a health insurance plan at the state exchange. The yearly premium cost of the unsubsidized, second to lowest level Silver plan in the area is $3,337. John’s income puts him at 257 percent of the federal poverty line, making him eligible for a premium tax credit.
Because John’s income is 257 percent of the FPL his maximum premium contribution is 8.27 percent of his yearly income, which is $2,480. Now to determine his tax credit we subtract $3,337 (the amount of the unsubsidized second-lowest Silver plan) from $2,480 (his maximum premium contribution or 8.27 percent of his annual income).
This gives John an annual tax credit of $897, which is paid directly to the insurance company that John signs up with at the exchange.
Bear in mind though that the cap is only for the premium at the Silver level. There are three other levels of plans to choose from at the exchange. You can still receive your premium tax credit for the higher planes, but the amount of the credit does not increase.
Take for a further example that John wanted to purchase the Gold level plan. The premium for that plan would be more expensive than the Silver level premium from which his tax credit was calculated. But he would still receive the $897 premium tax credit. The same goes for John if he decides on a lower cost Bronze level plan instead of the Silver.
Please note though that if your annual income exceeds 400 percents of the of the FPL then you will not be eligible for a tax credit when purchasing health insurance at the New York State Health Benefit Exchange.
4. Insurance plans sold through New York State of Health need to cover certain essential benefits.
Any health insurance plan sold through New York State of Health will need to include coverage for medical services in the following 10 categories in accordance with the Affordable Care Act legislation:
Ambulatory patient services, such as doctor’s visits and outpatient services
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Rehabilitative and habilitative services and devices
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
States will also play a role in determining which minimum essential benefits will be covered under the Affordable Care Act.
5. If you like your current health insurance, you can keep it
If you were already insured on March 23, 2010 when the Affordable Care Plan was signed into law or you are currently enrolled in a plan that existed prior to the ACA’s signing, then your plan is eligible to be “grandfathered in.” That means you will be able to keep you current plan as is.
Please note though that some insurance companies or employers may choose not to grandfather in some of their health insurance plans.
If your current plan is not eligible to be grandfathered in or if it is discontinued, you should receive notice from your insurance company.
For the correct information, make sure to check with your employer or health insurance company.
Businesses: What you need to know about the Affordable Care Act
1. The Employer Mandate
If your business employs at least 50 full-time workers then you are subject to the employer mandate, that is, to provide your workers with health insurance sometime in either 2015 or 2016. This plan is called The Employer Shared Responsibility Payment.
Originally the plan was to implement the employer mandate at the same time as the individual mandate. However, in early July 2013, the Obama administration opted to delay the employer mandate for a year.
According to numbers from the White House, many small businesses already provide their workers with some form of health insurance. It may also be worth noting that the vast majority of small businesses in the United States employ fewer than 50 full-time workers, and will thus not be subject to the Affordable Care Act’s employer mandate.
If your business does fall into the mandate range, and you do not offer your workers health insurance, you will be subject to a penalty. According to the Congress Research Services, the penalty is, “Number of full-time employees minus thirty multiplied by 2,000.”
2. SHOP Exchange
New York small businesses with 50 or fewer employees will have access to the state’s Small Business Health Insurance Options Program (SHOP), which is a health insurance exchange created just for small businesses.
There, businesses can shop for health insurance plans, tailored specifically to their needs. Businesses owners can then offer a choice of plans and carriers to their employees and pay only one bill directly to the SHOP exchange for the plans chosen.
The federal government announced that it would be delaying the opening on the SHOP Exchanges through the marketplace until November 1st, 2014. By 2015, those with 50 or less employees will have access to SHOP, and by 2016, those employers with a team of 100 or less will have the ability to use SHOP.
New York is one of the states that operated its own health exchange and has said they still plan to launched the SHOP Exchange in 2013 alongside the individual exchange.
3. Tax Credit
Businesses with fewer than 25 employees paying average salaries of less than $50,000 who choose to offer their workers health insurance through the SHOP Exchange will qualify for a tax credit. In fact this tax credit is already in place for small businesses, currently it covers up to 35 percent of the cost of health insurance.
In 2014, that number increases to cover up to 50 percent of costs. However it will then only be available to businesses who provide their employees coverage through the SHOP Exchange.
Businesses will also be able to claim a business expense deduction for the amount the premiums paid that exceed the tax credit. That means those businesses will receive a tax credit and a tax deduction.
4. Affordability is not an option
Businesses with 50 or more full-time employees are required to provide them with affordable health insurance. That means the insurance plan must cover at least 60 percent of medical expenses, and not cost an employee more than 9.5 percent of their annual income. If a business fails to meet those requirements, it will pay a penalty.
Grandfathered plans are not subject to the affordability requirement.
If a business of 50 or more full-time employees offers no health insurance then the employer faces an annual penalty of $2,000 times the number of full-time employees minus 30. That amount is scheduled to increase each year with the growth in insurance premiums.
If a business does provide health insurance, but workers still choose to seek coverage at the exchange then the business will face a penalty of $3,000 per worker that goes to the exchange. This number is also pegged to the growth in insurance premiums each year.
Frequently Asked Questions about the New York State Health Insurance Marketplace
Who’s eligible for a plan through the Health Benefit Exchange?
All U.S. citizen or legal permanent residents are eligible to purchase insurance through the public health benefits exchange.
How much does the New York State exchange insurance plan cost?
Health insurance plans sold through the New York State marketplace will on average be less expensive than they were in 2013. According to The New York Times Article, “Health Plan Cost For New York Set To Fall 50 percent,” this 2014, expect rates to be half of what they were in 2013.
New York State released information about the cost of these health insurance policies in 2013. These prices could still change, but you can view the tentative numbers here.
Can I buy any other kinds of insurance through the exchange?
Health insurance and dental insurance will be available for purchase through the New York State Health Benefit Exchange.
Doesn’t my employer have to offer me health insurance?
That depends on the size of your employer. For companies employing at least 50 full-time workers, working a minimum of 30 hours per week, they are required to at least offer a health insurance option to their employees.
Companies employing less than 50 full-time workers are exempt from the employer mandate, and can choose not to offer their employees health insurance without penalties.
How much are my premiums going to go up?
Premiums are expected to rise with the Affordable Care Act, but it’s not known how much they’ll increase by. According to some experts, premiums may increase by as much as 30 percent, while other say any increases will be negligible.
However, many customers can expect to see a significant savings when purchasing through the New York State Health Benefit Exchange because of premium tax credits.
What’s the difference between an exchange plan and going through a private insurer?
When going through a private insurance company, individuals will not receive the possible premium tax credit they might have received had they gone through the exchange. Also, plans previously sold through private insurance companies can be grandfathered in.
How much do I need to pay if I don’t want health insurance?
Under the Affordable Care Act everyone is mandated to have health insurance coverage or pay a penalty that increases every year.
For the first year the fee will only be $95 for an individual or 1 percent of income, whichever is higher. In 2015 that penalty goes up to $325 or 2 percent of income. Then, in 2016 the penalty increases to $695 or 2.5 percent of income. By 2017, the increase in penalty will be tied to an annual cost of living adjustment and based on inflation.
What does percentage of the federal poverty line mean?
It means your annual total income measured against that year’s definition of the federal poverty level. This number is used when calculating your premium tax credit.
See where you stand using our health care reform calculators.
How do I calculate my income vs. the percentage of the federal poverty line?
We recommend calculating your income vs the federal poverty line using this calculator
What is New York State of Health?
New York State of Health is the official name of the New York State Health Plan Marketplace, also known as the New York State Health Benefit Exchange. It will be an open marketplace where individuals and families can search for and then purchase affordable health insurance as part of the Obama Administration’s Affordable Care Act.
What types of plans does New York State of Health offer?
The exchange will offer insurance plans at four different levels that at least meet the minimum requirements for insurance plans sold under the Affordable Care Act.
What will be offered are tiered insurance plans broken down into “Metals”; bronze, silver, gold, and platinum level insurance plans. The plans are further broken into Healthy NY, HCTC Healthy NY or Non-Group/Individual HMO/PSO.
When did the marketplace open?
The summer of 2013, insurance companies began unveiling their plans and offering plans to customers through the New York State Health Benefit Exchange. However, it was on October 1st, 2013 that the first enrollment period opened.
Where can I find marketplace plans online?
The marketplace is accessible through the link here.
You can shop at the marketplace right now on our website by clicking here, and compare all of the plans available at The New York State Health Benefit Exchange.
What is Medicaid?
Medicaid is a federally subsidized health insurance program for low income and disabled individuals who are not insured through their spouse or employer and cannot afford to purchase health insurance.
Each state runs their own Medicaid program, and the eligibility requirements differ from state to state. There is usually a minimum threshold of age and/or income.
What if I already have insurance?
If you are enrolled in a health insurance plan that existed prior to the Affordable Care Act becoming law on March 23, 2010, then you can choose to keep that same plan after the roll out of the majority of the ACA provisions on Jan. 1, 2014.
This is called having your insurance plan, “grandfathered in”.
However not all insurance companies or businesses may choose to grandfather in their plans. For the best information contact your insurance company or your human resource department.
How does this affect my Healthy NY plan?
On January 1st, 2014, Healthy NY ceased to provide care for individuals and solos, but rather only pursing small businesses. Its benefits will match the benefits of a Gold plan which could bring up the price.
Those individuals who were enrolled in a Healthy NY plan on March 23, 2010 when the Affordable Care Act was signed into law are eligible for grandfathered status. Individuals and sole proprietors not eligible for grandfathered status will be moved over to the exchange.
At the exchanges, the equivalent health insurance coverage to the Healthy NY plans will be plans sold at the gold level.
Am I going to get a tax break to help pay for my health insurance?
Maybe. If your income falls between 138 and 400 percent of the Federal Poverty Line (FPL) you will receive credit paid directly to your insurer to help offset the cost of health insurance. It should also be added that these tax credits will only be available to those purchasing health insurance through the health care exchange and who qualified for the subsidy.
The credit will be set up on a sliding scale so the lower your income the bigger your tax credit.
What is the SHOP Exchange?
The Small Business Health Options Program, or SHOP, is a separate health insurance exchange created as part of the Affordable Care Act exclusively for small businesses. The SHOP exchanges will help employers search for affordable insurance plans for their workers and then easily enroll them.
If I get Medicare, how does the exchange effect me?
If you receive Medicare, the exchanges should not affect you at all. You will continue to get your health benefits uninterrupted.
Can I keep my same doctor when I’m picking out my new exchange plan?
Doctors are associated with health plans. If a doctor belongs to Oxford and a person joins an Oxford plan on the exchange, then they should be able to see that same doctor.
Don’t forget, you also have the option of grandfathering in your plan if the plan existed prior to March 23, 2010 when the Affordable Care Act was signed into law.
The History of Health Insurance in New York State
New York State has one of the country’s most progressive health insurance systems. Since 1990, New York State residents have enjoyed the benefits of community rating and guaranteed issue. These two laws are key components of the Affordable Care Act that went into effect on March 23rd, 2010.
Respectively community rating and guaranteed issue means insurance companies cannot charge people more based on their background or medical history, and deny health insurance coverage to anyone for any reason.
These two laws have expanded health insurance coverage to many New Yorkers since their introduction more than 20 years ago. However, these two policies have also contributed to higher health insurance costs in the state.
Prior to the Affordable Care Act being enacted and allowing these two laws to now become a right for Americans, some experts thought health insurance rates nationwide would increase. By some estimates premiums were said to rise by as much as 30 percent, according to a study released by the Society of Actuaries.
In New York. however, it was thought that health insurance rates could actually fall by as much as 14 percent when the rest of the Care Act was to take effect, according to the same study.
Again, prior to the Affordable Care Act, states that already have community rating and/or guaranteed issue laws on the books like Maine, Vermont, Massachusetts, and New Jersey thought they’d also see the same cost declining effect.