What do New York State residents need to know about the Affordable Care Act?

October 3, 2013 by Stephanie H. Smith

As a Human Resources Director, I have probably fielded more PPACA-related questions than most. For the record, I refuse to refer to this long-overdue and much-needed law, officially known as the Patient Protection and Affordable Care Act, as "Obamacare."

New York State has its own Health Plan Marketplace, available to state residents, with info at nystateofhealth.ny.gov.New York State has its own Health Plan Marketplace, available to state residents, with info at nystateofhealth.ny.gov.Rather than launching into an overheated diatribe about how the PPACA is law (and a great starting point for solving this country’s healthcare issues), and no amount of foot-stomping and tantrum-throwing will change that, I’ll attempt to explain what the PPACA means to anyone who might actually need it.

If you are unemployed or under-employed and uninsured, the Marketplace was specifically designed for you. You're likely to be able to obtain subsidized coverage, dropping your premiums to something that’s meant to be affordable.

If you are insured and your employer is partially or fully subsidizing your employee-only premiums (I’ll address dependents in a moment), chances are good that the Marketplace (originally called the Exchange) will do very little for you. Unsubsidized premiums will either be higher than what you’re already paying (and without the pre-tax benefit) or about the same, but for less-robust plans.

You may find that it’s better for you to stay on your employer’s plan, but for your spouse and child to obtain coverage from the Marketplace, since many employers make insurance available for family members, but don't help you pay for it. Again, review the options, so you can make an educated decision. No one is going to force you to buy insurance from the Marketplace, if you have access to other coverage. You always have the choice of keeping what you already have. 

Right now, the Marketplace can give you a fair idea of what else is out there. You may discover that your employer’s plan is much better than you ever realized, comparably. Or, you may find a solution to the high cost of covering your family on your employer’s plan. Just remember that if your employer’s plan meets the definition of "affordable" and complies with the basic coverage requirements outlined in the PPACA, you will probably not be eligible for a subsidy to lower the quoted premiums.

I urge everyone to comparison shop. If you know an accountant or a fairly number-savvy HR professional, ask for help with crunching numbers and assessing your risks – both health and financial. Many plans offer fairly low (unsubsidized) premiums, but they fall under the definition of a "high-deductible health plan," which would require you to pay large out-of-pocket amounts, even for in-network coverage. Those deductibles are not subsidized, so don’t rush to enroll in the lowest-cost plan.

Do be aware that if you find a plan that will meet your needs, you can enroll now, but your coverage will not start until January 1, 2014. You should not need to pay any premiums until mid to late December, but the premium billing is handled by each carrier, so don’t hold me to that.

If you choose to remain uninsured, be advised that you can be charged a penalty and you will be 100% responsible for any medical costs you incur. In 2014, the penalty is 1% of your annual income or $95, whichever is higher. The penalty will go up each year, so in 2016, it will be 2.5% of your annual income or $695, whichever is higher. The fee for uninsured children is $47.50, with a family cap of $285.

It bears mentioning that children may be eligible for CHIP (Children’s Health Insurance Program), which is a separate program. Within New York State, the program is called Child Health Plus.

Regardless of your political views, the PPACA does do a handful of things that help everyone, not just those obtaining their coverage from the Marketplace:

  • It guarantees that you will never again be denied coverage, or charged higher premiums, due to a pre-existing condition. The only exception is for private (non-group) plans that are "grandfathered."
  • Children can now remain on their parents' coverage until the age of 26, even if they're married and not enrolled in school full-time.
  • Preventive care is now free for adults. This applies to annual physicals, including gynecological check-ups for women.

New York’s Marketplace is called "NY State of Health," and can be found at nystateofhealth.ny.gov. There are plans available for individuals and families, as well as for small employers.

Stephanie H. Smith is the human resources director for a commercial and residential real estate company in New York City.



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