New York State Marketplace Update

The NY State of Health, a health plan marketplace where individuals, families, and small businesses can browse and purchase health insurance. MetroPlus Health Plan, the plan of choice for half a million New Yorkers offers those Qualified Health Plans or QHP at an affordable rate for you and your loved ones.

For more information about MetroPlus and NY State of Health, go to: www.nystateofhealth.ny.gov

Below are several frequently asked questions that will provide guidance on several topics around the NY State of Health, what it means to the residents of New York, and finding the right plan for you.

Frequently Asked Questions:

Enrolling in a Plan
There are three main ways to enroll in a Marketplace Plan.

Online: 
NY State of Health allows you to compare plans and look at rates on their website. Click here

Phone:
MetroPlus Health Plan
Member Services
1.855.809.4073
TTY users: 711
Monday through Saturday, 8 am - 8 pm

In Person:
Certified Application Counselors, navigators, brokers, agents and assistors will be available to help you enroll in the Marketplace. Need to find a MetroPlus rep near you? Click here. 
Health Reform Questions Everyone Should Know

What is Health Reform?

The Affordable Care Act (ACA), officially known as the Patient Protection and Affordable Care Act (PPACA) but commonly referred to as “Obamacare,” is a collection of new health care laws. You may have heard people talk about it as “Health Reform.” The laws affect most people, including employers, health care providers, individuals, and health plans such as MetroPlus Health Plan. The goal is to improve access to affordable health coverage for everyone.

What is the Marketplace?

Beginning 2014, individuals, families, and small business (SHOP) employers will be eligible to purchase health insurance through an online marketplace, offered by the NY State of Health. The Marketplace serves as a compilation of health plans sold by private insurers (such as MetroPlus Health Plan), where people can compare options, shop, and learn if they are eligible for financial assistance.
 
Each state has a choice to either create its own State based exchange, State Partnership Exchange or participate in the Federally Facilitated Exchange (FFE). New York is participating in the State Based Exchange (SBE). The State Based Exchange is comprised of two parts, the Individual Exchange, where individuals can shop for health insurance on their own, and the Small Business Health Options Program (SHOP), which employers with 2-100 full-time employees can purchase a health insurance plan for their employees.

Do I have to purchase health insurance?

Starting in 2014, most people are required to have health insurance or pay a penalty. Coverage may include employer-provided insurance, individual insurance, or insurance through a government program such as Medicare or Medicaid.

Several groups are exempt from the requirement to obtain coverage or pay the penalty, including:
  • People who would have to pay more than 8 percent of their income for health insurance
  • People with incomes below the threshold required for filing taxes
  • People who qualify for religious exemptions
  • Undocumented immigrants (illegal residents)
  • People who are incarcerated
  • Members of Native American tribes

What is the penalty if I do not purchase health insurance?

If you don’t have coverage, you will pay the higher of these two amounts:
  • $695 per adult, $347.50 per child, and up to $2,085 per household, or
  • 2.5% of your yearly household income
Note: In 2016, individuals and families with income under approximately $83,400 will pay a flat dollar penalty amount if they fail to obtain minimum essential coverage. Individuals and families with income over $83,400 will pay a penalty equal to $2.5 percent of their income.

When is Open Enrollment and when will I be covered?

  • November 1, 2016: Open Enrollment starts — first day you can enroll in a 2016 insurance plan through the Health Insurance Marketplace. Coverage can start as soon as January 1, 2017.
  • December 15, 2016: Last day to enroll in or change plans for new coverage to start January 1, 2017.
  • January 1, 2017: 2017 coverage starts for those who enroll or change plans by December 15.
  • January 15, 2017: Last day to enroll in or change plans for new coverage to start February 1, 2017
  • January 31, 2017: 2017 Open Enrollment ends. Enrollments or changes between January 16 and January 31 take effect March 1, 2017.

After open enrollment is complete, New Yorkers can still purchase a health plan during the Special Enrollment Period (SEP). During this time, those that wish to enroll must to have experienced a 'qualifying event.'

Qualifying events include:
  • Losing coverage through your employer plan
  • Aging off parent’s health plan at age 26
  • Your health plan loses Qualified Health Plan status
  • Gaining or becoming a dependent
  • Gaining or losing subsidy status
  • Citizen status change
  • Relocation out of health plan’s service area
  • Enrollment errors of the Marketplace

Is MetroPlus Health Plan participating in the Marketplace?

Yes – MetroPlus Health Plan will participate on the Marketplace, offering plans for individuals, families, and small businesses. Please note, small businesses with 51 or more full-time eligible employees will be able to participate on the SHOP in the future.

What do individuals need to do to get ready?

If you are enrolled in a health plan and have questions about renewing, click here.

The following is a list of things you can do to make sure you are ready:
  • Educate yourself on the different types of health coverage being offered (through an employer, insurance carrier, or online marketplace)
  • Find out if your employer will offer coverage or if you need to purchase an individual plan.
  • Are you under age 26? You may be able to stay on a parent’s health plan until you reach age 26. There will be an option to purchase riders to extend coverage through age 29.
  • Understand how deductibles, copayments, and coinsurance work.
  • Gather information on your household income – can you qualify for a subsidy or cost-sharing reduction or other government program (Medicare/Medicaid)?
  • Set your budget. Larger premiums usually mean lower out-of-pocket costs for prescription drugs, office visits, and procedures, and vice versa.  How much of a premium can you afford, and how much can you spend out of pocket for Deductibles, Coinsurance, and Copayments?
  • Individuals and small groups should consider renewing early (December 1). Please check with your sales representative for details. The Marketplace will process the renewals, but MetroPlus is here to help.
*Please visit healthcare.gov to find out if you can be excluded from the health insurance requirement.

How do I get discounted (commonly referred to as “free”) health insurance? Individuals and small businesses should consider renewing early (December 1).

Depending on your income level and other factors, you could qualify for Medicaid, Medicare, or a subsidy through the NY State of Health Marketplace. To estimate your eligibility, click here for the Kaiser subsidy calculator.
  • If you are below 100 percent of the Federal Poverty Level (FPL), you could qualify for Medicare or Medicaid. Please visit The Center for Medicare and Medicaid Services for more information and to find out if you qualify.
  • 100 – 400 percent of the FPL, you could qualify for an advanced premium tax credit (subsidy) that will lower your monthly premium. The subsidies can only be used on plans sold on the NY State of Health Marketplace.
  • If you are 100 – 250 percent of the FPL and are receiving a subsidy, you could be eligible for a cost-sharing reduction that can reduce out-of-pocket costs, including Coinsurance, Deductibles, Copayments, Maximum Out-of-Pocket, or any combination. You have to purchase a Silver-level plan on the health insurance Marketplace to receive the reductions. No additional applications are needed.

Where can people go for information?

You can speak with a MetroPlus Health Plan representative, your employer’s benefits administrator, or your broker. In addition, you can find information on the following websites:
What is an HSA or Prime Plan?

What is an HSA Plan?

HSA is a health savings account, similar to a savings plan for your health care. HSA plans are only offered through the NY State of Health Marketplace to individuals and families. 

MetroPlus Health Plan offers BronzePlus HSA. Interested in BronzePlus HSA, click here

Some benefits include:
  1. There is no use it or lose it rule: So, any money saved in an HSA account is always yours.
  2. You keep your money with you if you change plans* be it within the same year or different year. 
  3. You can use an HSA to pay for qualified medical expenses (including doctor and hospital visits, co-payments, eyeglasses, prescriptions, certain long-term care insurance premiums and COBRA premiums) now or at any point in the future – even in retirement.
  4. HSA funds can use accumulated tax-free contributions to pay for health care costs for self/spouse and any tax dependents
*To use HSA funds you must be enrolled in a high deductible plan that is HSA compatible


Contribution maximums for High deductible HSA compatible plans for 2017:
 
Coverage Contribution Limit Catch-Up Contribution Limit* Total Contribution Limit
Self-Only $3,350 $1,000 $4,350
Family $6,750 $1,000 $7,750

*Eligible individuals who are over age 55 but under age 65
 
There are rules about who can open and contribute to an HSA, how it's used, and how taxes work, so be sure to do your research before you take action. 

Health Savings Accounts and Other Tax-Favored Health Plans

Read more information provided by the Department of the Treasury - Internal Revenue Service (IRS). 
Click here.
 

What is a Prime Plan?

Prime plans are health plans that provide incentives to members just for seeing their Primary Care Provider (PCP). MetroPlus Prime plans offer three (3) visits to a PCP that are not subject to deductibles. Members must see a PCP for a specialty that is family medicine, internal medicine, pediatric medicine, obstetrics/gynecology or outpatient mental health services. Prime plans are only offered through the NY State of Health Marketplace to individuals and families. 

MetroPlus Health Plan offers SilverPrime and GoldPrime. Interested in SilverPrime, click here. Interested in GoldPrime, click here.
 
For more information on COBRA, click here.
Special Enrollment Period (SEP)
Individuals and families who experienced a qualifying life event are also eligible to enroll during SEP. Special Enrollment occurs after Open Enrollment, around February of the next coverage year. 

Qualifying Life Events include:
  • Loss of health insurance
  • A move into New York State
  • Marriage or domestic partnership
  • Divorce or legal separation
  • Pregnancy
  • Birth or adoption of a child, or placement of a child in foster care
  • Becoming a citizenship, national or lawfully present individual
  • Gaining or continuing status as a member of an Indian tribe or an Alaska Native shareholder. Members of federally recognized Indian tribes and Alaska native shareholders can sign up for or change plans once per month throughout the year.
  • For people already enrolled in Marketplace coverage: Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions

You must notify the NY State of Health within 60 days when you experience a Qualifying Life Event

MetroPlus Marketplace Plans are available for enrollment during SEP. Individuals who are eligible for Essential Plans, Medicaid, Child Health Plus, and Medicaid Special Needs Plan can enroll year round.

How can I find out which program I am eligible for?

  • Apply online at nystateofhealth.ny.gov
  • Call the Member Services at 1.855.809.4073
  • Meet with an in-person assistor

There are three ways you can enroll:

Choose us Online:

NY State of Health, the official Health Plan Marketplace – or Exchange – lets you compare plans and look at premium rates on their website. Visit nystateofhealth.ny.gov/.

Call us by Phone:

Call MetroPlus Member Services at 1.855.809.4073, TTY users: 711, Monday through Saturday, 8 am – 8 pm. We’ll see if you qualify and help you enroll in the health plan that’s right for you.

Visit us in Person:

Marketplace Facilitated Enrollers (FEs), Navigators, brokers and agents are available to help you enroll in the Marketplace. Call us at 1.855.809.4073, TTY users: 711, Monday through Saturday, 8 am – 8 pm to make an appointment

For more information about SEP, check out the NY State of Health website.

 
Additional Information

Where is MetroPlus' service area?

The Bronx, Brooklyn, Manhattan, and Queens. Staten Island is also available to Marketplace and Essential members. 

Where can I go to enroll?

MetroPlus Health Plan organizes several enrollment events across New York City. Representatives can be found in NYC Health + Hospitals associated facilities and health centers, at MetroPlus health kiosks located in malls in Brooklyn and Queens and at various community locations run out of our mobile units. 

For more information about enrollment, other health plans or to speak with someone from MetroPlus Near You, click here.

Where else can I go if I have any questions regarding the Marketplace?

The NY State of Health will provide a toll-free call center and website with up-to-date information. The website is http://nystateofhealth.ny.gov. MetroPlus is always available online or through Member Services at 1.855.809.4073, TTY users: 711, Monday through Saturday, 8 am - 8 pm.

Who is exempt from a penalty for not obtaining health insurance?

  • If you are an undocumented immigrant
  • If you are incarcerated
  • If you are a member of an Indian Tribe
  • If your family income is below the threshold requiring you to file tax return ($9,350 for an individual, $18,700 for a family in 2010)
  • If you have to pay more than 8% of your income for health insurance, after taking into account any employer contributions or tax credits