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?
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?
The following is a list of things you can do to make sure you are ready:
If you are enrolled in a health plan and have questions about renewing, click here
*Please visit healthcare.gov to find out if you can be excluded from the health insurance requirement.
- 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.
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: