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New York Health Benefit Exchange

New York Health Benefit Exchange, or New York health insurance coverage, was established as a direct result of the Affordable Care Act, commonly referred to as ObamaCare. Instead it provides a marketplace where private insurance companies can sell highly-regulated policies.

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Eric Stauffer is a former insurance agent and banker turned consumer advocate. His priority is to help educate individuals and families about the different types of insurance they need, and assist them in finding the best...

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UPDATED: Jul 26, 2020

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New York Health Benefit ExchangeThe New York health insurance exchange (officially named the New York Health Benefit Exchange) was established as a direct result of the Affordable Care Act, commonly referred to as ObamaCare. The new law required that every state create their own exchange for individuals, families and small businesses to purchase health insurance, or the federal government will step in and create one for them.

How the Health Benefit Exchange Works

The exchange itself does not actually offer insurance coverage. Instead it provides a marketplace where private insurance companies can sell highly-regulated policies. In order to get listed on the exchange, insurance companies must provide policies that meet very specific criteria for coverage and coinsurance.

The primary plans sold through the New York Health Benefit Exchange come in four tiers – Bronze, Silver, Gold, and Platinum. Each tier will have its own coverage limit assigned to it, which dictates the amount an insurance company will pay for received health care. The breakdown looks like this:

 

Category % Paid by Health Plan % Paid by Individual
Platinum 90% 10%
Gold 80% 20%
Silver 70% 30%
Bronze 60% 40%

 

In addition to the four tiers mentioned above, the New York exchange will offer catastrophe plans for those who qualify (individuals under 30). Catastrophic plans carry high out-of-pocket costs but comparably low premium payments. These types of plans are not good for someone who visits a health care provider with any frequency, but can provide a safety net should a major accident arise.

You can view the approved monthly premium rates for each plan type and company here.

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Essential Health Benefits

In addition to increasing the number of people covered by health insurance, another goal of the Affordable Care Act is to increase the actual benefits that health care coverage offers. This set of minimum coverage items is referred to as essential health benefits. In order for an insurance company to sell a policy on the New York Health Benefit Exchange, they must offer the following coverage items as part of their insurance package:

  •  Ambulatory Patient Services (doctor visits)
  • Emergency Services
  • Prescription Drugs
  • Hospital Visits
  • Maternity Coverage
  • Mental Health
  • Rehab Services
  • Laboratory Results
  • Pediatric Services
  • Newborn Care

The effective date that these services will be added to all individual and small group policies sold on the exchange is January 1st, 2013.

New York Open Enrollment

The New York Health Benefit Exchange has open enrollment from October 1st to March 31st for the following year’s coverage. That means by signing up sometime between October and December, the plan will take effect on January 1st and continue through December 31st. As with many employer-sponsored health insurance plans, if you do not make adjustments during the next open enrollment period, your policy will continue as-is, or adopt the changes the insurance company adds to the policy.

During open enrollment, citizens of New York will be able to shop for health care online, over the phone, in person, or through the mail. The new exchange setup allows for direct comparisons between the different plans, and streamlines the ability to compare exact coverage types across different companies.

New York Health Care Subsidies

Individuals and families may qualify for federal tax credits depending on their annual household income. Unlike many other government assistance programs, people making up to 400 percent of the federal poverty level may still qualify for these subsidies. That means a family of four making less than $94,000 a year could still get assistance paying for their health insurance.

New York residents that qualify for a subsidy do not necessarily have to wait until tax time to get their money back. The federal program allows for individuals and families to claim their subsidies when signing up for health insurance and get their premiums reduced right away. This is very beneficial for people that cannot afford to wait all year for their refund. However, it means you must be accurate when forecasting you annual income or risk having to pay back any subsidy funds should you make over the stated threshold.

Only people getting health insurance through the New York Health Benefit Exchange can qualify for the federal tax subsidies.

About Eric Stauffer

Author: Eric StaufferI am a former insurance agent and banker turned consumer advocate. My priority is to help educate individuals and families about the different types of insurance they need, and assist them in finding the best place to get it.

2 Comments

  1. My husband, David, and I are both “retired”. My husband continues to work full time and has private insurance from his company which covers us both. This year the insurance had a $3000 spend down before it kicks in. While David’s Company contributes $2000 David will pay $80 weekly for the health insurance. My concern is what if it takes 3 quarters of a year or longer to pay up the spend down while at the same time we’re paying over $300 a month for insurance that we’re not getting.

    Though I’m not sure that will happen, my husband had a heart problem before we got married seven years ago and I have been diagnosed with diabetes within the past year or so.

    We were wondering if it would be less expensive if we went on Medicare Parts B, C & D and a supplement? Can you advise us?

    Susan

    Reply
    • Hi Susan,

      “Spend-down” usually refers to Medicaid, and it is when you make more than the allotted amount to qualify. So lets say you make $1,000 more a month in income than Medicaid allows, you can often make a claim once you have spent $1,000 in a given month on qualified health care. Please note the claim can only be for anything over the monthly spend-down amount.

      As far as Medicare parts B, C and D, that is going to take sitting down and going over the numbers for your specific situation. Since no one can know for certain what kind of health care needs they will need in the future, it is best to calculate for many different scenarios and finding what makes the most sense. Unfortunately I cannot give an exact recommendation based on limited information.

      Reply

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