Overview of New York’s Health Insurance Exchange
When the Affordable Care Act was passed in 2010, states gained the opportunity to build health insurance marketplaces called exchanges. The state of New York's exchange is called NY State of Health. If you do not have health insurance or your health insurance costs too much, you can enroll in health coverage through NY State of Health starting October 1, 2013.
Qualified health insurers and plans in New York include: Affinity Health Plan, American Progressive (Today's Options NY), Blue Cross Blue Shield of Western NY, Blue Shield of Northern Eastern NY, Capital District Physicians Health Plan, EmblemHealth, Empire BlueCross / Empire Blue Cross Blue Shield, Excellus Blue Cross Blue Shield, Fidelis Care, Health Republic Insurance (NY CO-OP), Healthfirst New York, Independent Health, MetroPlus Health Plan (Market Plus), MVP Health Plan, Inc., North Shore LIJ, Oscar Insurance Corporation, and UnitedHealthcare.
Qualified dental insurers and plans include Blue Cross Blue Shield of Western NY, Blue Shield of Northern Eastern NY, Delta Dental Insurance Company, Dentcare, Dentegra Insurance Company, Emblem, Empire BlueCross / Empire Blue Cross BlueShield, Guardian, Healthplex, MetLife, and Solstice.
Per the Affordable Care Act, all plans must offer the following essential services:
- Ambulatory patient services (doctor visits)
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices (Habilitative services are for people with disabilities who need speech, occupational, or physical therapy.)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Some plans will offer additional benefits, including adult dental and vision coverage.
Check out the helpful FAQs on the official NY State of Health website for more information about the basics of the marketplace.
There are four basic plans available, all with varying levels of coverage: Bronze (60 percent of expenses paid by plan), Silver (70 percent), Gold (80 percent), and Platinum (90 percent). The lower plans have lower premiums, but higher out-of-pocket costs. A catastrophic plan is available for folks under the age of 30. This plan has a high deductible.
Adults living at or below 133 percent of the federal poverty level (also known as the FPL, which is $11,490 a year in wages for one person and $23,550 a year in wages for a family of four), or pregnant women living at or below 218 percent of the FPL, can qualify for Medicaid in New York, based on eligibility standards that take effect January 1, 2014
Additional federal financial protections that begin in 2015 include a maximum annual out-of-pocket cost of $6,350 for individuals and $12,700 for families. Capping out-of-pocket costs will help consumers pay medical bills that aren’t covered by insurance, reducing the chance of bankruptcy.
The average premium for an individual choosing catastrophic coverage in New York is $170 a month. The estimated cost of the Silver Plan, based on reported averages from the providers in New York, ranges from $271 to $650 per month for a single adult. There is also a cap on out-of-pocket spending for each tier, based on income level. The cost table can be found here.
New Yorkers can now view available plans and estimated costs using the Tax Credit & Premium Estimator and shop, compare and enroll in plans after October 1, 2013. There is also an interactive map of offered health plans that shows New York residents the plan options available in their areas, as well as a full list of all available plans by borough and county.
As a guide, the estimated range in monthly payments for an individual, with no dependents, earning $35,000 per year on a Silver Plan across three New York counties is below:
- Broome: $292 to $380 monthly
- Erie: $275 to $467 monthly
- Kings (Brooklyn) and New York (Manhattan): $271 to $554 monthly
People want to how much their subsidies are, but the real question is how much will you pay? Once you figure out what the maximum healthcare percentage is for your income, then you know that's the most you'll have to pay for a Silver Plan (you may pay less). For example, if your income is $32,500 a year (283 percent of the poverty level), the most you’ll have to pay for health insurance is nine percent of your income, which amounts to $2,926 a year, or $244 a month. The challenge is to look at the cost of Bronze, Silver, Gold, and Platinum, and decide which plan offers the best value for you. An online calculator offered by the Kaiser Family Foundation provides an estimate of your subsidy eligibility and how much you should expect to spend on health insurance.
Information on Subsidies
There will be available subsidies in the form of tax credits, as well as cost-sharing programs for individuals and families. Tax credits are available for those with incomes up to 400 percent of the federal poverty level. People who have employer-based insurance may also apply for a credit if the cost of that coverage is more than 9.5 percent of their income. Cost-sharing programs are only available for those who enroll in the Silver Plan. These programs are also based on income as a percentage of the federal poverty level.
To learn more about NY State of Health, please visit http://www.nystateofhealth.ny.gov or call 1-855-355-5777.
QUESTION(s): I have gotten my price quotes for various plans available to me on the NYS Exchange. How do I obtain a list of coverage for the Silver Plan versus the Gold Plan versus the Platinum Plan to determine which plan I would like to enroll in for a specific insurance company?
Price quotes and premiums estimates are not always able to provide an accurate picture of what your health insurance will cost. But they can be a helpful predictive tool. When you complete the application process and apply for health insurance through the NYS Exchange, you will see your health insurance options presented in three tiers. The first tier divides your options by metal level: bronze, silver, gold, or platinum. Catastrophic is also an option but is available to a limited number of individuals. The second tier divides the plan by insurance company brand. The final tier divides the insurance plans by the type of health plan: HMO, PPO, high-deductible health savings plan, and so on.
The level of coverage you want will depend largely on how much money you want to spend in monthly premiums and how much you want to spend if and when you need to use your insurance. For example, platinum health insurance plans have the largest monthly premiums. They also require you to pay less co-insurance (out-of-pocket expenses) when you do use your health insurance. A bronze health insurance plan requires you to pay less in monthly premiums but more in co-insurance when you visit the doctor. A bronze plan may also have a higher deductible than a platinum plan.
Which metal tier you select depends on how much coverage you need, how much you can afford to spend each month, and how often you plan to use your insurance. All of the metal tiers still cover the same 10 basic essential health services.