New York's health benefit exchange: lots of questions, some answers

Joan Hohauser of Freeport has questions about how New York's health benefit exchange, which opens this Tuesday, will work.

Established as part of the federal Affordable Care Act, the exchange, called NY State of Health, is an online marketplace of health insurance plans for individuals and their families and small businesses with 50 or fewer employees.

Hohauser wants to know if all the plans will have high deductibles. Will she be able to find one with her doctors? How hard will it be to sign up for a plan? Where can she get help navigating the exchange?

The answers to these and other questions are critical to the 52-year-old former librarian with back problems who says about a quarter of her income now goes to pay for her own health insurance.

"I would like to be able to buy a robust health insurance product that enables me to see doctors and specialists when and if I need to see somebody without triggering a high deductible," she said.

There are thousands of Long Islanders like Hohauser. About 2.7 million New Yorkers have no health insurance and millions more have insurance they can barely afford. The state anticipates about 1.1 million will get health insurance through the exchange. On Long Island, about 400,000 are uninsured and close to 150,000 are expected to get insurance there.

According to the state, premiums on the exchange will be an average of 53 percent lower than those offered currently to individuals and families who buy coverage for themselves -- a small and expensive portion of the health insurance market. In Nassau, nine insurers are selling plans to individuals; in Suffolk, eight insurers are participating -- which is the national average, according to a federal study. Three insurers are selling plans to small businesses.

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Answers to some of Hohauser's questions won't be clear until Tuesday and after. But here are the broad outlines of how the exchange is to work:

What kind of health care can you get?

Ten health services must be covered by every plan sold on NY State of Health. They include: Care at a doctor's office; emergency services; hospital care; pregnant mother and baby care; mental health and addiction treatment; prescription drugs; rehab and skill development services and devices; lab services; prevention and wellness services and chronic disease management; and dental and vision care for children.

No one can be denied coverage because of a pre-existing condition and the state requires all plans to have adequate networks of doctors and hospitals.

Coverage begins Jan. 1, 2014, and people have until March 31 to buy insurance.

How can I sign up?

You can sign up on the website. Or you can call a free customer-service number and talk with someone on the phone. The state has also trained "navigators" you can meet with to help figure what plans are best for you or whether you are eligible for financial assistance. Many insurance brokers have also been through certified training to assist small businesses or individuals.

How are plans broken down?

Most health insurers will offer plans for individuals in five categories: catastrophic -- with the least expensive premiums -- and four "metal" tiers: bronze, silver, gold and platinum, with bronze charging the least costly premiums of the tiers and the highest out-of-pocket costs.

What is catastrophic coverage?

Catastrophic coverage is only open to individuals 30 and younger and not available to small businesses.

Monthly premiums are the cheapest -- starting on Long Island as low as $171 -- but the deductible is high. The standard deductible for catastrophic care is $6,350. After you have paid the deductible for catastrophic coverage, you have no other charges except your monthly premiums. This insurance primarily is used to cover medical emergencies, although three primary care visits are covered in full and not subject to the deductible.

What about metal tiers?

Monthly premiums go up with the metal tiers. On Long Island, monthly premiums for individuals start at $285 a month for bronze; $360 for silver; $439 for gold, and $516 for platinum.

For small businesses on Long Island, monthly premiums for individuals start at $334 for bronze; $408 for silver; $477 for gold, and $561 for platinum.

What about out-of-pocket expenses?

The metal tiers are associated with how much someone would pay in out-of-pocket expenses vs. a monthly premium. For example, in the bronze plan, an individual would be responsible for, on average, 40 percent of the costs, including deductibles and co-pays, of all covered benefits. In the silver plan, an individual would be responsible, on average, for 30 percent of the costs for services; for gold, it would be 20 percent, for platinum, 10 percent.

Which tier you should choose depends on what you can afford and your medical needs. If you are healthy, a plan with lower monthly premiums and higher out-of-pocket costs might be best. If must see the doctor often, a plan with a higher monthly premium and lower out-of-pocket costs might make sense.

What if I can't afford any policy?

You might qualify for a tax credit and/or cost-sharing reduction. Many single adults earning less than $45,960 and families of four earning less than $94,200 could qualify for a tax credit to reduce their premiums. Most single adults earning less than $28,725 and families of four earning less than $58,875 could also qualify for a cost-sharing reduction that lowers co-payments and deductibles. These are estimated when you apply for insurance.

Or you might qualify for Medicaid, for which you can also sign up through the state's Web portal.

What information would be useful to have before I consider which plan to choose?

Stacy Villagran, director of grants administration at the Nassau-Suffolk Hospital Council, said it is sensible to contact your doctors beforehand to see which plans on the exchange they are accepting. Be sure to specify you are looking for plans on the exchange.

What documents do I need?

The portal is paperless and the computer should have relevant information. But if your earnings or residence has changed in the last year you might need some documents. If you have moved recently, you will need some proof of your current address if the computer has a different address. If your income has changed within the last year -- say, you lost your job -- a copy of your pay stub or unemployment insurance check could help you qualify for a tax credit. You will also have to provide your Social Security number. If you are a legal immigrant, you will need your residency identification card so your number can be entered into the portal.

What if I run a small business?

Employers have several options if they join SHOP, which stands for Small Business Health Options Program: You can choose among plans offered by a specific carrier; select specific plans offered by multiple insurers; select a metal tier, or allow employees to select their plan.

You can also choose what kind of contribution you wish to make to your employees' coverage: an uncapped percentage of the premium (such as 50 percent); a capped percentage (such as 50 percent up to $300) or a defined dollar amount (such as $300 a month). Employers are not required to make a contribution toward their employees' health insurance.

What about a tax credit?

Small businesses with fewer than 25 employees with an average annual salary of $50,000 or less who contribute at least 50 percent of the employees' premiums can apply for a tax credit of up to 35 percent for small businesses and 25 percent for tax-exempt groups. In 2014, the tax credit will increase up to a maximum of 50 percent of the employer's contribution, 35 percent for tax-exempt organizations.

Many insurance brokers have taken certified training and tax advisers may be able help you with specific tax information. To see whether a broker has been certified by the state, you can go to the NY State of Health website or call the customer service number.

WHERE DO I GO FOR HELP?

NY State of Health customer service: 855-355-5777. Hours: Monday-Friday 8 a.m. to 5 p.m. As of Tuesday, the hours will be: Monday-Friday 8 a.m. to 8 p.m. and Saturday 9 a.m. to 1 p.m. Or go to the website: nystateofhealth.ny.gov.

The state has designated three lead organizations to help Long Islanders navigate the exchange. For information or to find out when and where you can meet with someone who will help you enroll, contact:

Nassau-Suffolk Hospital Council: 631-656-9783; coverage4healthcare.com.

Public Health Solutions: 646-619-6500; email navigator@healthsolutions.org

Community Service Society: 888-614-5400; cssny.org; email enroll@cssny.org. (The Community Service Society has subcontracted with five other agencies who will also be serving parts of Long Island.)

Other websites that may be helpful:

Small Business Assistance Program: guilderlandchamber.com/sbap/index.html

Tax credit and premium estimator: nystateofhealth.ny.gov/PremiumEstimator

NY State of Health plans map: nystateofhealth.ny.gov/PlansMap