Health Insurance 101
Health Care Reform
The Affordable Care Act and You
The implementation of the Affordable Care Act has changed how people get health insurance and health care. If you have had a hard time getting insurance in the past — or haven’t had coverage at all — these changes may be a very big deal. If you already have health insurance, it’s important to know what is different under the Affordable Care Act and how those changes could affect you.
It also may be helpful to know about a New York state law that took effect in March 2015, which gives people with health insurance protection against “surprise” health care bills from health care providers that aren’t in their insurer’s network.
Affordable Care Act FAQs
How has health insurance changed under the Affordable Care Act?
The Affordable Care Act — enacted in 2010, phased in over several years and often referred to as “Obamacare” — has made significant changes in the way health insurance is sold and what it covers. Here are some of the biggest:
- All major medical health insurance plans have to cover certain services that are considered “essential health benefits.” These services fall into the categories of preventive and wellness visits to a doctor, emergency care, prescription drugs, lab tests, and maternity and newborn care, among others.
- If you are currently ill or suffer from a chronic health problem, such as asthma, high blood pressure or diabetes, you can’t be turned down for insurance or charged more for your policy. The same goes for your children and other dependents.
- Health insurance companies cannot charge women a higher premium than men for the same plan.
- It’s easier to comparison-shop. Insurance companies offer plans in a number of standardized categories (Catastrophic, Bronze, Silver, Gold and Platinum), and your premium won’t be affected by your medical history. That means you can get an idea of what different insurers’ plans would cost you, and what services you would get in return.
- You can get many kinds of preventive services without a copay or coinsurance. Those services include mammograms, immunizations and routine screenings, such as cholesterol and blood pressure tests.
- Your children can stay on your family plan until their 26th birthday. (Under state regulations, they also may be able to stay on the plan until their 30th birthday if you purchase a rider — an amendment to the insurance policy — at the time you enroll.)
- Health insurance companies cannot place a dollar limit on how much they will spend for your covered benefits, either in a plan year or during the entire time you are enrolled in a plan. In other words, there are no longer annual limits or lifetime limits on health insurance plans. This change protects you from having to pay out of pocket again when your medical bills for covered benefits reach a certain amount.
What happens if I don’t have health insurance?
The Affordable Care Act includes a requirement that most people either have health insurance or pay a penalty. (There are some exceptions to this requirements – see below.) In 2016, the penalty for not having health insurance is $695 per adult and $347.50 per child, or 2.5% of your yearly household income, whichever is bigger. You’ll pay the penalty on the federal income tax return you file for the year in which you don’t have coverage. If you don’t pay it, the IRS will hold back that amount from any future tax refunds. You might not have to pay the penalty, however, if you were uninsured for no more than two consecutive months during the year.
Who isn’t required to purchase health insurance?
The federal government allows for a number of exemptions from the requirement to have health insurance. A partial list appears below. Some of these exemptions can be claimed on your federal tax return. For others, including hardship exemptions, you must submit a paper application.
You may be exempt from the health insurance requirement if:
- The lowest-priced coverage available to you would cost more than 8.05% of your household income.
- You don’t make enough money to file a tax return.
- You lived in a state that didn’t expand its Medicaid program, but you would have qualified if it had.
- You’re a member of a federally recognized tribe or eligible for services through an Indian Health Service provider.
- You belong to a recognized health care sharing ministry.
- You belong to a recognized religious sect that has longstanding religious objections to insurance (including Medicare and Social Security).
- You’re a U.S. citizen living abroad.
- You’re incarcerated.
- You’re not in the United States legally.
- You have experienced a hardship that affected your ability to buy insurance, such as bankruptcy, domestic violence or a recent eviction.
How can I get health insurance?
You can get health insurance in a variety of ways. One is through your employer, if your employer offers it. You can also buy insurance directly from insurers or health maintenance organizations (HMOs), from agents or brokers, or on public or private marketplaces.
A health insurance marketplace allows you to compare insurance plans and enroll in one. You may also be able to find out whether you’re eligible for a subsidy to make your chosen plan more affordable. New York’s public marketplace is New York State of Health. Many of the plans sold by CareConnect are on it.
What if I can’t afford insurance?
Low-income individuals and families can get help paying for health insurance in three ways:
- The federal government may help you pay some or most of the insurance premium (the monthly payment you make to stay on your plan). Whether you can receive that subsidy — and how big the subsidy will be — depends in large part on how much you earn. You may qualify for assistance if your income is between 100% and 400% of the federal poverty level (for example, up to $47,080 for an individual and $97,000 for a family of four for enrollment in 2016 plans). Our Get a Quote tool will estimate whether you’re eligible for a subsidy and how much it might be. You can get a more definitive answer when shopping for health insurance on New York State of Health (you must purchase your plan on New York State of Health to receive a subsidy).
- You may be eligible for a plan that includes a cost-sharing reduction (CSR) — a government-subsidized discount that lowers the amount you have to pay out of pocket on your medical bills. You can get CSR if your income is between 100% and 250% of the federal poverty level and you purchase a health insurance plan in the Silver category through New York State of Health.
- You may be able to take advantage of another government-subsidized option: an essential plan (EP), also referred to as a basic health plan (BHP). This type of plan will be available in the state of New York starting in November 2015 for people with incomes as high as 200% of the federal poverty level. It can reduce both monthly payments and out-of-pocket costs. CareConnect is not offering EPs in 2016.
As a small-business owner, can I get help with my costs for providing insurance to my employees?
Some small businesses are eligible for a health care tax credit that can cover as much as 50% of their contribution toward employee premium costs. Generally speaking, the smaller the business, the bigger the credit it receives.
To qualify, as of 2015, all of the following must apply
- You have fewer than 25 full-time-equivalent employees.
- Salaries for your employees average about $50,000 or less per year.
- You pay at least 50% of your full-time employees’ premium costs.
- You offer coverage to your full-time employees through the Small Business Health Options Program (SHOP) marketplace. For employers in New York, this is available on New York State of Health.
How long can I keep my children on my policy?
If your health insurance plan offers dependent coverage, your children can stay on your family policy until their 26th birthday. In addition, according to New York regulations, they may be able to stay on your plan until their 30th birthday if you purchase a rider (an amendment to the insurance policy) at the time you enroll.
Can I be denied insurance if I have a pre-existing condition?
Under the Affordable Care Act, you cannot be denied insurance for a pre-existing condition. You also cannot be charged a higher premium for your plan due to a pre-existing condition.
When do I need to choose a plan?
Open enrollment for 2016 coverage begins Nov. 1, 2015, and ends Jan. 31, 2016. After that cutoff, you won’t be able to enroll in a plan unless you qualify for a special enrollment period because of specific life events, such as marriage, the birth of a child, or the loss of other health insurance (for example, if you are laid off and lose the coverage provided by your job).
The coverage you buy during open enrollment will begin on Jan. 1, 2016, or later, depending on when you enroll.
New York’s Health Insurance Marketplace FAQs
What is New York State of Health?
New York State of Health was set up by the state government in 2013 as the official public marketplace for health insurance for individuals, families and small businesses. The marketplace also is sometimes referred to as a health insurance exchange. Individuals, families and small businesses can use New York State of Health to compare insurance plans, calculate costs and purchase coverage.
Individuals and families also can use the marketplace to find out if they are eligible for a subsidy that can make insurance more affordable. In addition, it helps them check their eligibility for Medicaid and Child Health Plus and sign up for these programs.
For qualified employers, using New York State of Health to purchase insurance for their employees provides access to the small-business health care tax credit, which can cover as much as 50% of the employer contribution toward employee premium costs.
What kinds of health plans are available on New York State of Health?
There are five categories of health plans offered on the marketplace: Bronze, Silver, Gold, Platinum (the “metal” plans) and Catastrophic.
The metal plans all include the same benefits; they just differ in what you will pay. Bronze plans have the lowest premiums but the highest deductibles, copays and other cost-sharing features — so you will pay less upfront, but more if you need care. The other plans have progressively higher premiums and lower cost-sharing requirements — all the way up to Platinum plans, which have the most expensive monthly premiums, but also the most generous benefits.
Catastrophic plans provide safety-net insurance; they are meant to protect against financial disaster if you need a lot of care, but they provide little coverage for routine needs. They cover three visits to a primary care provider each year and provide preventive care with no out-of-pocket costs, but you will pay a high deductible before any other coverage kicks in. You must be under 30 to buy a catastrophic plan or have a hardship exemption from the Affordable Care Act requirement to buy a plan with more coverage.
What do the health plans cover?
All health plans for individuals that are sold on the marketplace must provide coverage for services deemed “essential health benefits.” This means that, generally speaking, every plan must cover certain services in the following categories:
- Outpatient services (care you receive without being admitted to a hospital)
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse disorder services, including behavioral health treatment
- Prescription drugs
- Services and devices that help you recover if you are injured, or assist you if you have a disability or chronic condition
- Laboratory services, such as blood tests
- Preventive and wellness services
- Chronic disease management
- Pediatric services, including dental and vision care for children until their 19th birthday
When can I enroll in a plan on New York State of Health?
There are several important dates to keep in mind if you are enrolling in a plan on New York State of Health:
- Nov. 1, 2015: The start of open enrollment — the first day you can enroll in a 2016 marketplace plan
- Jan. 1, 2016: The earliest date your 2016 health insurance coverage can start
- Jan. 31, 2016: Open enrollment for 2016 plans ends
What happens if I miss the open enrollment deadline?
If you don’t act by Jan. 31, you can’t enroll in a health insurance plan for 2016 unless you qualify for a special enrollment period. The length of the special enrollment period varies. For policies available in the marketplace, you may qualify for a special 60-day enrollment period following specific life events that involve a change in family status (such as marriage or the birth of a child) or the loss of other health coverage. Job-based plans must provide a special enrollment period of 30 days.
New York’s Protection From Surprise Bills and Emergency Services
A New York law that took effect in March 2015 (Financial Services Law Article 6) protects patients from “surprise bills” — meaning bills for health care services, other than emergency services, that are performed by an out-of-network provider at an in-network hospital or in-network ambulatory surgical center (a nonhospital health care setting where surgery is performed) without the patient’s approval for out-of-network care. A “surprise bill” can also result when an in-network doctor refers an insured person to an out-of-network provider — for example, by taking a blood sample from the patient in the office and then sending it to an out-of-network laboratory — without the patient’s approval. The new law also protects consumers from bills for emergency services.
The following information explains what you need to know about these important protections if:
- You have coverage with a health maintenance organization (HMO) or an insurer subject to New York law. (CareConnect is an insurer subject to New York law.) Note: These protections took effect on March 31, 2015, for policies and contracts issued or renewed after that date.
- You are uninsured or your employer or union provides self-insured coverage that is not subject to New York law.
- You are a health care provider.
What you need to know to protect yourself from surprise bills if you have coverage with an HMO or insurer subject to New York law (coverage that is not self-insured; CareConnect is an insurer subject to New York law)
What is a surprise bill?
When you receive services from an out-of-network doctor at an in-network hospital or ambulatory surgical center, the bill you receive for those services is a surprise bill if one of the following applies:
- An in-network doctor was not available.
- An out-of-network doctor provided services without your knowledge.
- Unforeseen medical circumstances arose at the time the services were provided.
It is not a surprise bill if you chose to receive services from an out-of-network doctor instead of from an available in-network doctor.
When you are referred by your in-network doctor to an out-of-network provider, the bill you receive for those services is a surprise bill if you did not sign a written consent that you knew the services would be out-of-network and would result in costs not covered by your health plan. A referral to an out-of-network provider occurs in any of the following circumstances:
- During a visit with your in-network doctor, an out-of-network provider treats you.
- Your in-network doctor takes a specimen (such as a blood specimen) from you in the office and sends it to an out-of-network laboratory or pathologist.
- You receive any other health care services when referrals are required under your plan.
How can I protect myself from a surprise bill?
You will be protected from a surprise bill and will be responsible only for your in-network copayment, coinsurance or deductible if you do both of the following:
- Sign an assignment of benefits form to permit your provider to seek payment for the bill from your health plan.
- Send the form to your health plan and to your provider, and include a copy of the bill or bills you do not think you should pay. CareConnect members should send the form and bill (or bills) to the attention of the Appeals and Grievances Department in one of two ways:
- Scan and send them in an email to firstname.lastname@example.org
- Mail them to:
Attn: Appeals and Grievances Department
2200 Northern Blvd., Suite 104
East Hills, NY 11548.
What you need to know about surprise bills if you are a health care provider
What are my obligations if my patient has coverage through an HMO or insurer subject to New York law (coverage that is not self-insured)?
Hospital and ambulatory surgical center. A bill is a surprise bill if your patient receives services from an out-of-network doctor at an in-network hospital or ambulatory surgical center and:
- An in-network doctor was not available; or
- An out-of-network doctor provided services without your patient’s knowledge; or
- Unforeseen medical circumstances arose at the time the health care services were provided.
Referral. A bill is a surprise bill if your patient is referred by an in-network doctor to an out-of-network provider, and your patient did not sign written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient’s health plan. A referral occurs if:
- During the course of a visit with an in-network doctor, an out-of-network provider treats the patient; or
- The patient’s in-network doctor takes a specimen from the patient in the office (for example, blood) and sends it to an out-of-network laboratory or pathologist; or
- The patient receives any other health care services when referrals are required under the patient’s plan.
Assignment of benefits form. When your patient signs an assignment of benefits form for a surprise bill, your patient will be responsible for paying you only the in-network cost-sharing. You are required to hold your patient harmless for any amounts in excess of your patient’s in-network cost-sharing, and your patient’s health plan will pay you directly for the services. The health plan is required to pay you the billed amount or attempt to negotiate reimbursement with you. If attempts to negotiate do not result in a resolution of the payment dispute, the health plan will pay you an amount that it determines is reasonable. You may dispute the amount that the health plan pays you through the independent dispute resolution process.
When you bill a patient. If you are a doctor and are billing a patient for what could be a surprise bill, you are required to include an assignment of benefits form and a claim form for a third-party payer when you send the bill to the patient.
Emergency services (Insurance Law Section 3241(c) and Financial Services Law Article 6)
What are “hold harmless protections” for insured patients?
Your health plan must protect you from bills for out-of-network emergency services in a hospital if you have coverage through an HMO or an insurer subject to New York law (coverage that is not self-insured). You do not have to pay out-of-network provider charges for emergency services (typically for services in a hospital emergency room) that are more than your in-network copayment, coinsurance or deductible (this protection may apply only if your health insurance coverage was renewed after March 31, 2015). Let CareConnect know if you receive a bill from an out-of-network provider for emergency services.
What are my options as a doctor?
You may dispute the amount that the health plan pays you for emergency services through the independent dispute resolution process if you do not participate with a patient’s health plan. However, the following emergency services are exempt from the that process: CPT codes 99281–99285, 99288, 99291–99292, 99217–99220, 99224–99226 and 99234–99236, if the bill does not exceed 120% of the usual and customary cost and the fee disputed is $613.50 (adjusted annually for inflation rates) or less after any applicable coinsurance, copayment and deductible.
The independent dispute resolution (IDR) process (Financial Services Law Article 6)
As a health care provider, how do I submit a dispute with a health plan involving an insured patient?
You should submit your dispute through the independent dispute resolution (IDR) process for surprise bills or emergency services. As a provider, you must:
How do I submit a dispute if I’m an uninsured patient, a patient with employer or union self-insured coverage, or an insured person who did not sign an assignment of benefits form for surprise bills?
To submit a dispute, you must complete this application and send it to the New York State Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
Who do I contact if I have questions about submitting a dispute?
For help, call the New York State Department of Financial Services at 800-342-3736 or email IDRquestions@dfs.ny.gov.
What is the IDR process for the review of surprise bills and bills for emergency services?
This process includes several components:
- An independent dispute resolution entity (IDRE) reviews the dispute. Decisions will be made by a reviewer with training and experience in health care billing, reimbursement, and usual and customary charges, in consultation with a licensed doctor in active practice in the same or a similar specialty as the doctor providing the service that is the subject of the dispute. The IDRE will make a determination within 30 days of receipt of the dispute.
- The IDRE determines the fee. For disputes involving HMO or insurance coverage, the IDRE chooses either the out-of-network provider bill or the health plan payment. For disputes submitted by uninsured patients, or by patients with employer or union self-insured coverage, the IDRE determines the fee.
- The IDRE considers these factors when making a determination:
- Whether there is a gross disparity between the fee charged by the provider and (1) fees paid to the provider for the same services provided to other patients in health care plans in which the provider is out-of-network, and (2) the fees paid by the health plan to reimburse similarly qualified out-of-network providers for the same services in the same region
- The provider’s training, education, experience and usual charge for comparable services when the provider does not participate with the patient’s health plan
- The circumstances and complexity of the case
- Patient characteristics
- The usual and customary cost of the service
- The IDRE may direct a good-faith negotiation for settlement if settlement is likely or if the health plan’s payment and the provider’s fee are unreasonably far apart.
- The review is binding and admissible in court.
Who pays for the IDR?
For disputes between a provider and a health plan involving an insured patient, these are the possible outcomes:
- The provider pays the cost of the dispute resolution when the IDRE determines that the health plan’s payment is reasonable.
- The health plan pays the cost of the dispute resolution when the IDRE determines that the provider’s fee is reasonable.
- The provider and the health plan share the pro-rated cost when there is a settlement.
- The provider or health plan submitting the dispute may be charged a minimal fee if the dispute is found ineligible or incomplete.
For disputes involving a patient who is not an insured, these are the possible outcomes:
- The doctor pays the cost of the dispute resolution when the IDRE determines that the doctor’s fee is not reasonable.
- The patient pays the cost of the dispute resolution when the IDRE determines that the doctor’s fee is reasonable, unless it would pose a hardship to the patient. (“Hardship” means a household income below 250% of the federal poverty level.)
Who should I contact if I have questions about independent dispute resolution?
If you have questions or need help completing an application, call the New York State Department of Financial Services at 800-342-3736 or email IDRquestions@dfs.ny.gov.