These young adult coverage changes apply now to newly purchased plans. For existing plans, the changes will apply when the health plan policy is renewed. Click here to learn more.

NY Bridge Plan is New York State’s pre-existing condition insurance plan, which was created by and receives federal funding under the federal health care reform law.

As of March 2, 2013, NY Bridge Plan is no longer accepting new enrollment.  Current enrollees will continue to receive coverage until the end of 2013.  Click here to learn more.

Last Updated: February 26, 2013

Starting in the 2010 tax year, self-employed parents can include any premiums they pay to cover their young adult children (up to age 27) when calculating the self-employed health insurance deduction.

Beginning in 2013, the threshold for deducting medical and dental expenses will rise from 7.5% to 10% of AGI for taxpayers under 65. The increase won’t take effect until 2017 for seniors.

For the 2010 tax year, self-employed workers could reduce their net earnings subject to self-employed (SE) tax by the amount that they paid for health insurance premiums, including for spouse and dependent coverage. This additional tax break was only available for the 2010 tax year.

For more information about the Self Employed Health Insurance Deduction, click here.

High income workers include individuals whose wages exceed $200,000, and couples whose combined wages exceed $250,000. This change reflects a 0.9% increase to the Medicare Hospital Insurance component of FICA that will be paid entirely by the worker.

Self-employed high income workers will be responsible for paying the full 0.9% increase, and cannot deduct the value of that increase for income tax purposes. This means that when filing income taxes, the self-employed FICA deduction will continue to be 7.65%.

For more information on this change from a private tax consulting firm, click here.

Also beginning in 2013, high-income tax payers with unearned investment income (including interests, dividends, annuities, royalties, and rents) will be subject to a 3.8% tax on that income.

Last Updated: October 23, 2012

As part of federal health care reform, New York has received federal money, including Consumer Assistance Program (CAP) grants, to expand the help available to residents and small businesses who have questions or problems with their health insurance.

New York State’s Consumer Assistance Program is run by the non-profit Community Service Society of New York (CSS) under a contract with the State’s Department of Health. CSS operates a statewide network of community-based non-profit organizations, known as Community Health Advocates (CHA).  Through this network, CHA has expanded the consumer assistance services available to New Yorkers who would like help with both private and public health insurance issues.

The Small Business Assistance Program (SBAP), an expansion of the Community Health Advocates program, is specifically dedicated to helping small businesses in New York - including the self-employed - with health care and health insurance concerns.

You can learn more about Community Health Advocates and the services it offers, as well as other consumer assistance available to New York residents here.

Last Updated: October 24, 2012

For example, existing health plans are limited in the changes they can make and still retain grandfathered status. According to interim regulations, if any of the following six types of changes are made to an existing benefits package, the plan will lose grandfather status. In brief, these changes are:

1. Elimination of all or substantially all benefits to diagnose or treat a particular condition.
2. Increase in a percentage cost-sharing requirement (e.g., raising an individual’s co-insurance requirement from 20% to 25%).
3. Increase in a deductible or out-of-pocket maximum by an amount that exceeds medical inflation plus 15 percentage points.
4. Increase in a co-payment by an amount that exceeds medical inflation plus 15 percentage points (or, if greater, $5 plus medical inflation).
5. Decrease in an employer’s contribution rate towards the cost of coverage by more than 5 percentage points.
6. Imposition of annual limits on the dollar value of all benefits below specified amounts.

Additionally, to be considered a grandfathered plan, a health plan must comply with certain record-keeping and notification requirements.

Sole proprietors may switch insurers and still maintain grandfathered status as long as the structure of the ‘new’ plan does not violate any of the other rules (e.g., no significant reduction or cutting of benefits, no increase in percentage cost-sharing, etc.).

To learn more about the requirements for maintaining grandfathered plan status click here for information from the federal government.

Last Updated: August 2, 2011

The Summary of Benefits and Coverage (SBC) and Uniform Glossary are documents designed to help consumers understand their health insurance coverage and choices. 

·         The Summary of Benefits and Coverage (SBC) is a standardized 8 page document that outlines a health plan’s major benefits, costs and coverage limitations.  It also includes information on consumer rights, appeals and grievances, and coverage examples for some typical costs under the plan.  To view a sample completed SBC, click here.

·         The Uniform Glossary provides typical definitions for common health insurance terms such as “deductible” and “co-payment”, and includes  a graphic to help explain how cost-sharing features of a plan work.  To view the uniform glossary, click here.

Health plans must make the SBC and glossary available to enrollees at renewal, and within 7 business days of receiving a request from a potential purchaser or current enrollee.

Additionally, the Uniform Glossary, a list of the plan’s network of providers, and information about a plan’s prescription drug coverage must be available on an Internet website or similar informational resource.

If changes to the plan are made that significantly affect covered benefits or services, a “notice of modification” must be provided to enrollees no later than 60 days prior to the effective date of these changes.

These SBC and Uniform Glossary requirements do not apply to stand-alone dental or vision plans. 

For more information see this Fact Sheet at http://www.healthcare.gov/ or the following FAQs posted by the U.S. Department of Labor.

Whether a specific benefit requirement will apply to a particular health plan will depend, in part, on whether the plan was in existence prior to March 23, 2010 (the day health care reform became law) and is considered a “grandfathered plan” or not. Click here for a discussion of "grandfathered plans."

Plans purchased in the sole proprietor market prior to the enactment of federal reform that can claim grandfathered status only have to comply with certain new rules. These new rules will take effect when the health plan renews after September 23, 2010 and include:

• Prohibiting pre-existing condition exclusions for children under 19 - under NY law, insurers cannot deny coverage because of a pre-existing health condition, but they have been allowed to impose a waiting period of up to a year before they cover care for most pre-existing conditions under certain circumstances. Beginning in plan years on or after September 23, 2010, plans can no longer impose this year-long waiting period on coverage for pre-existing conditions for children under 19 years old.
  
  
• Removal of lifetime dollar limits - health plans will have to remove lifetime dollar limits on “essential health benefits”, which includes hospitalizations and maternity and newborn care.
  
  
• Annual limits - plans must raise their annual dollar limits over time, as follows:
  
  
  • For policy years between Sept 23, 2010 and Sept 23, 2011, the annual limit cannot be lower than $750,000
    
    
  • For policy years between Sept 23, 2011 and Sept 23, 2012, the annual limit cannot be lower than $1,250,000
    
    
  • For policy years between Sept 23, 2012 and January 1, 2014, the annual limit cannot be lower than $2,000,0000
    
    
  • In 2014, all annual limits on “essential health benefits” will be removed.
    
    Insurers can seek a waiver to delay compliance with these annual limits rules if they can demonstrate that their current annual limits are necessary to prevent a significant loss of coverage or increase in premiums. Insurers that have been granted waivers must tell consumers that their policy does not meet the minimum legal requirements for annual benefits. To read more about these rules and to see a list of plans that have been granted and denied waivers, click here.
    
    
• Prohibition on rescissions – health plans cannot refuse to pay for claims that they had previously accepted and covered except in rare cases such as enrollee fraud or intentional misrepresentation. Additionally, if a plan makes a legal rescission of coverage they must give enrollees 30 days notice.

Non-grandfathered plans (those purchased or changed after March 23, 2010, the day health care reform became law) have to comply with new benefit requirements when the health plan starts or renews after September 23, 2010. These new requirements include:

• Prohibiting pre-existing condition exclusions for children under 19 - under NY law, insurers cannot deny coverage because of a pre-existing health condition, but they have been allowed to impose a waiting period of up to a year before they cover care for most pre-existing conditions under certain circumstances. Beginning in plan years on or after September 23, 2010, plans can no longer impose this year-long waiting period on coverage for pre-existing conditions for children under 19 years old.
  
  
• Removal of lifetime dollar limits - health plans will have to remove lifetime dollar limits on “essential health benefits”, which includes hospitalizations and maternity and newborn care.
  
  
• Annual limits - plans must raise their annual dollar limits over time, as follows:
  
  
  • For policy years between Sept 23, 2010 and Sept 23, 2011, the annual limit cannot be lower than $750,000
    
    
  • For policy years between Sept 23, 2011 and Sept 23, 2012, the annual limit cannot be lower than $1,250,000
    
    
  • For policy years between Sept 23, 2012 and January 1, 2014, the annual limit cannot be lower than $2,000,000
    
    
  • In 2014, all annual limits on “essential health benefits” will be removed.
    
    
• Preventive care - health plans will have to cover certain preventive care services for children and adults. Plans cannot charge any cost-sharing (e.g., co-payments or coinsurance) for these preventive care services when provided in-network. However, if the preventive service is not the main reason for the visit to the doctor’s office or if this service is billed separately from the office visit, the health plan can require cost-sharing for non-preventive care received during the visit. To see a list of covered preventive care services on the federal HealthCare.gov website, click here. And for more information and background from the federal government on the preventive care requirement, click here.
  
  
• Emergency Services - co-payments and co-insurance for out-of-network emergency services can’t be greater than those for in-network emergency services. Enrollees also can’t be forced to pay a larger deductible or face a higher out-of-pocket maximum for out-of-network emergency services than they would for general out-of-network services. However, some sole proprietors who receive emergency care out-of-network may have to pay the difference between what the provider charges and what the health plan pays, up to certain limits. In NY, sole proprietors in HMO plans will not have to pay this difference. Click here to read more about this requirement on the federal HealthCare.gov website.
  
  
• Choice of Provider - if a plan requires you to select a primary care provider (“PCP”) or pediatrician, you can designate any in-network primary care physician or pediatrician that is accepting new patients.
  
  
• Females in plans that offer OB-GYN services and require you to pick an in-network PCP can see an OB-GYN and receive OB-GYN services without a referral or prior authorization.
  
  
• Prohibition on rescissions – health plans cannot refuse to pay for claims that they had previously accepted and covered except in rare cases such as enrollee fraud or intentional misrepresentation. Additionally, if a plan makes a legal rescission of coverage they must give enrollees 30 days notice.
  
  
• Appeals Process - for plans created or purchased after March 23, 2010, federal rules establish a standardized processes for consumers who want to appeal an insurer’s decision to deny a claim. This includes both appeals made through your health plan directly (internal review) and secondary appeals made through an independent reviewer (external review).
  
  
• Health plans’ internal appeals processes must comply with NYS and federal regulations. However, some new federal requirements have been delayed and may not take effect until plan years starting on or after July 1, 2011 or January 1, 2012, depending on the requirement.
  
  
  • For information on the timeframes for implementing the new federal requirements for internal appeals processes, click here.
    
    
• External appeals processes are subject to NYS regulations and, starting July 1, 2011, they may also be subject to new federal requirements.
  
  
• For information on NYS requirements, click here for a summary of internal review process requirements, and  click here for a summary of external review process requirements
  
  
  • For information on new Federal internal and external review requirements, click here.
    
    

Last Updated: October 26, 2012

The federal government issued guidelines for the coverage of additional preventive health benefits for women by new and non-grandfathered individual, sole proprietor, and group health plans.  These plans have to cover the following services consistent with the guidelines without cost sharing:

1. yearly well-woman preventive care visits to obtain recommended preventive services
   
2. screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes
   
3. high-risk human papillomavirus (HPV) DNA testing as part of cervical cancer screening for women over 30, no more frequently than every 3 years
   
4. counseling for sexually transmitted infections
   
5. counseling and screening for HIV
   
6. contraceptive methods, sterilization procedures, and patient education and counseling to prevent unintended pregnancies
   
7. lactation counseling and equipment to promote breast-feeding
   
8. screening and counseling to detect and prevent interpersonal and domestic violence

These services are in addition to ones that many health plans are already required to cover for women without cost sharing, including mammograms and screenings for cervical cancer.

An exempt religious employer is defined as one that:

1. Has as its purpose the instilling of religious values
2. Primarily employs persons who share its religious tenets
3. Primarily serves persons who share its religious tenets; and,
4. Is a non-profit organization

Non-profit, non-exempt religious employers that currently do not cover some or all forms of contraception in their group health plans are being granted a temporary enforcement “safe harbor”.

The safe harbor gives them until August 1, 2013, or when a plan first renews after this date, to meet the coverage requirements.

This safe harbor extension also applies to student health plans administered by non-profit institutions of higher education with similar criteria.

The federal government is in the process of developing alternative ways of ensuring contraceptive coverage for plan participants (i.e., individuals enrolled in the employer’s health plan) that will accommodate non-exempt, non-profit religious employers and non-profit institutions of higher education with an objection to contraceptive coverage.

Proposed methods for providing coverage that are under consideration include allowing non-exempt, non-profit religious employers to indicate their objections to contraception coverage and provide the health insurance company with a notice of their objection. If the employer self-insures the health plan, they would notify the third party administrator of the plan.

The health insurer or third party administrator, not the employer, would then be responsible for providing plan participants with access to the specified contraceptive services without cost sharing. 

Coverage requirements for these non-exempt employers will go into effect on or after August 1, 2013.

List of Services:
http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforWomenIncludingPregnantWomen
 
Brief Overview of Covered Services:
http://www.hrsa.gov/womensguidelines/

HHS Overview of new provisions
http://www.healthcare.gov/news/factsheets/2011/08/womensprevention08012011a.html

Last Updated: October 26, 2012

In 2012, more than 83,000 individuals (including sole proprietors), nearly 8,000 small businesses, and over 900,000 large businesses across New York State received rebates of more than $86.5 million.

For individuals, rebates can be distributed as a check, a reduction in future premiums or, if the plan was paid for with a credit card, a lump sum reimbursement to the account. 
 
For job-based coverage, the rebates go to the employer. Employers must use the rebates to benefit enrollees. 

Last Updated: October 29, 2012

Yes, at this point, New York plans to let more low-income adults get Medicaid starting in 2014.

Because NY already lets many low-income adults enroll in Medicaid, there won’t be a lot of people added to the program.  Plus, some adults at incomes higher than those levels in the ACA can already get coverage in NY through its Medicaid expansion program, Family Health Plus.

In NY, the ACA will mostly make Medicaid available to more low-income adults under 65 who don't have children.

Currently, adults without children can get public health insurance (Medicaid or Family Health Plus) if their income is up to 100% of the Federal Poverty Level (FPL).  For example, single adults cannot make more than $11,172 a year to qualify for public coverage now (in 2012).

By 2014, these adults with household incomes up to 133% FPL will be eligible for free or low-cost public coverage. The government sets the FPL each year, so what 133% FPL will mean in terms of household income in 2014 isn't known yet. To give you an idea, 133% FPL is around $14,800 for a single person in 2012.

No, immigration and residency requirements will still apply.

For example, low-income adults who are undocumented immigrants cannot get Medicaid now or in 2014, unless they are pregnant. Medicaid will also pay for medical care that is provided to treat an emergency condition. 

Unlike many other states, recent immigrants who are lawfully present can get public health insurance in New York, even if they have been here for less than 5 years. Residents who are “Permanently Residing Under Color Of Law” (PRUCOL), such as persons granted deferred action status, can also get Medicaid.

All children can get public coverage through the Child Health Plus program, even if they are an undocumented immigrant. 

To learn more about New York’s immigration rules for public health insurance, click here.

Last Updated: October 26, 2012

An Exchange – also referred to as a “marketplace” - is an organization that helps residents and small businesses purchase health insurance.

Under the Affordable Care Act (ACA), federally-approved Exchanges will be available in each state. In these Exchanges, eligible individuals, including self-employed workers, who buy private coverage can get financial help to lower their health insurance costs starting in 2014. Exchanges will also help consumers compare plans and enroll in coverage. 

Small businesses can buy coverage in the Exchange, too.  To learn about how NY’s Exchange will serve small businesses and their workers, click here.

Yes, there will be an Exchange in all states in 2014. 

A state can set up its own Exchange, but it must meet federal requirements.  If it does not, the Federal Government will operate the Exchange for the state.

New York is planning to operate its own Exchange.  On April 12, 2012, Governor Andrew M. Cuomo issued an Executive Order, creating New York’s Exchange.  It is  called the NY Health Benefit Exchange.   You can read the Executive Order here or the press release here.

On December 14, 2012, the Centers for Medicare & Medicaid Services (CMS) provided conditional approval to New York State to operate a state-based Exchange.  To read the conditional approval letter from Secretary Sebelius, click here.

To visit the NY Health Benefit Exchange website, click here.

Federal law requires NY’s Exchange to do certain things, such as:

• Help individuals and families enroll in health coverage.
  
  
• Allow individuals to apply for coverage online, over the phone, in-person and through the mail.  For example, NY’s Exchange will have a call center and a website where individuals can shop for and enroll in coverage.
  
  
• Allow individuals to fill out one application for both public health insurance and private coverage in the Exchange.
  
  
• Set up a program, called a Navigator Program, to help people understand their health insurance options and pick a plan that’s best for them. This help will be available in-person.
  
  
• Provide eligible individuals with financial help to lower their insurance and health care costs.  There are two types of help:  premium tax credits and cost-sharing reductions.  The premium tax credits (also called premium assistance) can be claimed in advance and applied to your monthly premiums. This means you will pay less than the full price each month for health insurance.  Or, you can choose to pay the full price of coverage and claim the tax credit at the end of the year.

The Exchange is mainly for uninsured residents and people who cannot get insurance through an employer.  Individuals must also live in New York and be a citizen, national, or immigrant lawfully present in the U.S. to get insurance in the NY Health Benefit Exchange.

Starting in 2014, self-employed workers, including sole proprietors, will also be able to buy insurance on the individual side of the NY Health Benefit Exchange.

Small businesses located in New York will also be able to purchase coverage in NY’s SHOP Exchange. For more information on coverage for small businesses, click here.

Undocumented immigrants cannot use the Exchange.  They are not eligible for financial help and they cannot buy insurance in the Exchange, even at full price.

Generally, individuals who have access to coverage through their employer will not be able to get financial help to buy insurance in NY’s Exchange.  However, there are two exceptions:

• If the employer’s coverage exceeds 9.5% of your household income, you and your family may be able to get coverage in the Exchange and receive financial help.
  
  
• If the employer’s coverage is inadequate, meaning it pays less than 60% of the cost of covered benefits, you and your family may be able to get coverage in the Exchange and receive financial help.

Plans in the Exchange will offer – at least - a set level of comprehensive benefits.

All plans in NY’s Exchange – and those sold outside of the Exchange to individuals and small businesses -  will offer, at the least, “essential health benefits”.

The Affordable Care Act (ACA) lists the 10 categories of essential health benefits:

• Ambulatory care
  
  
• Emergency services
  
  
• Hospitalization
  
  
• Maternity and newborn care
  
  
• Mental health and substance use disorder services, including behavioral health treatment
  
  
• Prescription drugs
  
  
• Rehabilitative and habilitative services and devices
  
  
• Laboratory services
  
  
• Preventive and wellness services and chronic disease management
  
  
• Pediatric services, including oral and vision care
  

The Federal government is letting states pick one of their most popular plans to act as a reference or benchmark for the scope of services and limits on benefits to be covered in the 10 essential health benefit categories in 2014 and 2015.

New York State selected the largest small group plan in the state, the Oxford EPO, to be its reference or benchmark plan. NYS will fill in required benefits not included in the Oxford plan in the following areas:

• Pediatric dental/vision coverage
  
  
• Habilitative services
  
  
• Mental health/substance abuse parity

The benefits covered by the Oxford EPO plan are described in Exhibit 3 of this report.

Plans in the Exchange will cover a range of health care costs.

• To make it easier to compare your options, health plans will be organized into 4 categories according to how much of the total cost of covered care a health plan is expected to pay. This is known as the plan’s “actuarial value.”
  
  Plans with a lower actuarial value will typically pay less and those with a higher value will typically pay more, as follows:
  
  
  • Bronze plans – will have an actuarial value of 60%
  • Silver plans – will have an actuarial value of 70%
  • Gold plans – will have an actuarial value of 80%
  • Platinum plans – will have an actuarial value of 90%
    
    In other words, Bronze plans will typically pay for 60% of the total cost of covered care while Platinum plans will typically pay for 90% of total costs. 
    
    Actuarial value is calculated based on the typical way a standard population utilizes health care services. How much a plan actually pays may differ from these “typical” amounts, depending on things like what services you receive and the specific design of the health plan.

Plans in the Exchange will limit the amount out-of-pocket you must pay.

• There will be limits the amount you will have to pay out of your own pocket (also known as your “out-of-pocket” costs) for covered services each year.
  
  
  • These out-of-pocket limits are the same as those set for plans that can be used with a health savings account (HSA).  The limits can change each year, but in 2012, out-of-pocket limits for HSA-qualified plans are $6,050 for self-only coverage and $12,100 for family coverage.  To learn more about health savings accounts, click here.

These limits only apply to in-network care. If your plan lets you go out-of-network for  care, your out-of-pocket costs could be higher.

Also, if your household income is below 250% of the federal poverty level, you may  be able to get financial help to lower your out-of-pocket costs even further if you  purchase coverage in the Exchange.

• Plans licensed and certified by NYS
  • NY intends to ask insurance carriers to submit an application to offer coverage in the Exchange in the beginning of 2013. Plans will have to be licensed by NYS, meet state and federal requirements, and agree to follow the Exchange’s rules in order to sell in the Exchange.  Plans selected by NY to offer coverage in the Exchange will be certified by the state.
    
    
• A Consumer Operated and Oriented Plan (CO-OP) being created by Freelancers Union
  • Freelancers Union received a federal loan to create a new insurer to offer a CO-OP plan in New York.  CO-OPs are to be private, not-for profit, member-run organizations that meet certain requirements.  To learn more about CO-OPs click here.
    
    
• Two plans overseen by the federal Office of Personnel Management (OPM)
  • OPM – the agency that manages benefits for federal employees – will oversee at least two health insurance plans to be provided in every state.  At least one of these plans will be a not-for-profit plan.  OPM will contract with insurers to offer these multi-state plans in Exchanges throughout the U.S.

Health plans will be able to offer a lower cost “catastrophic plan” to people who are under 30 or who are exempt from the requirement to purchase coverage based on federally defined criteria. (The federal government is expected to provide more details on these exemptions in the future.)

Catastrophic plans will offer, at the least, the same set of essential health benefits as other coverage, but similar to how high-deductible plans work now, you will have to meet higher deductibles before the plan starts to cover the cost of most care.

The Affordable Care Act included funding to support the creation of CO-OPs, new non- profit, member-run health insurers.

CO-Ops will offer qualified health plans in the health insurance Exchanges starting in 2014.  They also are permitted to sell coverage in the individual and/or small group market outside of the Exchange.

CO-OPs will be private, non profit, member-run organizations. Members are individuals covered by the CO-OP, and each adult member can vote for the board of directors. The majority of the board must be members of the CO-OP.

CO-OP profits must be used to lower premiums, improve benefits or invest in programs that will improve the quality of health care for its members. This differs from for profit insurers that pay a portion of their profits to shareholders.

In February 2010, Freelancers Health Service Corporation was awarded $174 million in loans to set up a CO-OP in New York.  Although sponsored by Freelancers Union, a membership and advocacy organization for independent workers, the CO-OP will operate as an independent organization. At this point in time, it is expected to offer individual coverage through the New York health insurance Exchange.

Like all qualified health plans offered in the Exchange, premium and cost-sharing subsidies will be available for eligible low income individuals. Enrollment in the CO-OP is expected to begin in the fall of 2013, with coverage starting in January of 2014. To learn more about the Freelancers CO-OP in New York, click here.

The Affordable Care Act set aside money to help private-sector, not-for-profit groups start CO-OPs. The money, which was available as low interest loans and grants that had be to repaid, was to help pay for startup costs and help these groups meet State financial requirements for health insurers.

Twenty-four organizations received loans to start CO-OPs before Congress eliminated most of the rest of the money to address the Fiscal Cliff at the end of 2012.  No more funds are available to help new organizations start a CO-OP.  However, some funds were left to help with administrative costs for the 24 organizations that had already received funds.

For More Information:

DHHS Overview of CO-OPS
http://www.healthcare.gov/law/features/choices/co-op/index.html

DHHS CO-OP Fact Sheet
http://www.healthcare.gov/news/factsheets/2011/07/coops07182011a.html

Freelancers CO-OP announcement
http://www.freelancersunion.org/co-ops/index.html

CMS CO-OP Overview
http://cciio.cms.gov/resources/factsheets/coop_final_rule.html

Last Updated: January 15, 2013

Starting in 2014, eligible residents can get financial help to lower the cost of their health plan. The help will come from the federal government.

This financial help, also called premium assistnace, is a type of tax credit that you can get even if you don’t owe any income taxes.  You can also get it during the year, so you won’t have to pay as much each month for health insurance.  Or, if you want, you can wait and claim the tax credit at the end of the year when you file your income tax return.

Financial help will be available to eligible individuals and families. This includes residents who:

• Are uninsured and not eligible for other health insurance such as Medicaid or employer-sponsored coverage
  
  
• Are uninsured because employer coverage is not affordable or adequate
  
  
• Are citizens, nationals or legal immigrants residing in New York
  
  
• Purchase insurance in NY’s Health Benefit Exchange
  
  
• For the most part, have household incomes between 133% and 400% of the Federal Poverty Level (FPL). The FPL is set by the government each year; as an example, 400% of the poverty level is $44,688 for an individual and $92,208 for a family of four in 2012.

Most residents with household incomes below 133% FPL will be eligible for free or low-cost public health insurance in New York. 

It is possible that residents with incomes between 133% and 200% FPL, and maybe some people with lower incomes, will get coverage in a new program, called a Basic Health Plan program. But NY has not decided yet if it wants to offer this program.

NY’s Health Benefit Exchange will be able to help you figure out if you are eligible for financial help. 

If you qualify for premium assistance, you can pay part of the plan’s premium each month. The federal government will pay the rest directly to your health insurance company.

If you choose to pay the full premium each month, you can get the premium assistance money back when you file your taxes at the end of the year. 

You can also just ask for part of the premium assistance now. That means you’d pay more each month than you have to pay, based on what you know about your income now, and you can get the rest back at the end of the year.

Since this assistance is a tax credit, even if you get it in advance (each month), it still has to be claimed when you file your household income taxes.  This means the amount of help you get in advance will be checked against what you can claim based on your final income for the year.  If when you complete your tax return it turns out you were eligible for more assistance than you got, you will get a refund.  If you got more than you it turns out you are eligible to get, you must pay some or all the money back, depending on your income.  Read more about this “reconciliation process” here.

The amount of premium assistance you can get will be based on your household income and the insurance plan you choose.  In general, you will not be required to spend more than a certain percentage of your household income on coverage.

The amount you have to pay will be based on a “benchmark” plan offered in NY’s Exchange.  The exact plan is not known now, but it will be the “second lowest cost Silver plan” offered in NY’s Health Benefit Exchange.  If you select a plan that is more expensive than this Silver plan, you will have to pay the additional cost.

For example, if your family income is from 133% to 150% of the federal poverty level (FPL), the amount your family will pay in health insurance premiums if you purchase this silver plan will be limited to 3% to 4% of household income. The financial assistance decreases and then stops as household income increases to 400% FPL. Families with incomes from 300% to 400% FPL are at the highest income levels eligible for subsidies. They will have to pay up to 9.5% of their income in premiums for a silver plan.

Here is a table that describes the maximum amount individuals or families may have to pay for all income levels.  This is the most you’d pay if you purchased the Silver “benchmark” plan.  Depending on how much plans cost in the Exchange, or if you select a lower-cost plan, you may pay less than this amount.

The penalty will depend on your individual circumstances, including your family size and household income. For example, penalties for children will be lower than those charged uninsured adults.

The penalty will start in 2014 and increase over time. By 2016, the maximum annual penalty will be $695 per adult and $374.50 per child, up to a total of $2,085 or 2.5% of taxable household income, whichever is greater. The applicable dollar amount (e.g., $695) will also be adjusted annually to reflect changes in cost-of-living index.

More information on the amount of penalty you may face if you or your family members do not have coverage is expected in the future.

Individuals who do not maintain health insurance coverage will have to pay a penalty unless they qualify for an exemption for one of the following reasons:        

• Their break in coverage is less than 3 months
  
  
• The lowest cost plan available to them exceeds 8% of their household income
  
  
• Their household income is below the tax filing thresholds
  
  
• They are members of recognized Indian tribes
  
  
• They have suffered a hardship with respect to their ability to obtain coverage, as will be defined by the federal government

The federal government is expected to provide more details on these exemptions in the future.

In addition, certain individuals are not subject to the requirement to maintain health insurance. These include immigrants who are not lawfully present in the U.S. (e.g., undocumented immigrants); incarcerated individuals; and people who can claim a religious exemption, including those who are members of a health care sharing ministry.

New York’s Health Benefit Exchange will provide “certificates of exemption” to those residents who qualify for an exemption from the mandate.

Last Updated: October 16, 2011