Qualified plans must include

ACA Simplified
• The Affordable Care Act (PPACA) was signed into law on March 23, 2010—
putting in place measures to improve access to affordable health care.
Starting January 1, 2014:
• Most Americans will have to purchase health insurance or pay a penalty:
• $95 or 1% of Income for 2014 – assessed on annual tax filing.
• Large employers (51 or more employees) may be subject to penalties if
they don’t provide insurance – Postponed until 2015
• Insurance companies will need to modify their plan offerings to meet
certain requirements of the ACA – QUALIFIED HEALTH PLANS
• Every state must have a Health Benefit Exchange, where individuals and
small businesses can shop for health coverage. An Exchange is an On-line
Digital Marketplace where consumers can go to shop for insurance.
• New York will have two Exchanges: an Individual Exchange (for Individuals
and Sole Proprietors) and a Small Business Health Options Program (SHOP)
Exchange (Businesses 2-50 employees)
Important Exchange Dates
• October 1, 2013: Open enrollment begins
• January 1, 2014: Effective date for plans
offered in the exchange and for penalties for
• March 31, 2014: Open enrollment ends
Small Business Compliance
• May purchase insurance through a broker or
directly from an insurance carrier
• May purchase coverage through NY’s SHOP
• Allow employees to shop the individual
Premiums & Benefits
• Plans sold in the exchange must offer a
minimum set of essential benefits
• Plans will be offered in platinum, gold, silver &
bronze tiers in the exchange
• Premiums must be the same for identical
polices whether sold in the exchange or off
the exchange
• Policies sold off the exchange may include
enhanced benefits such as wellness programs
Qualified Plans
Guaranteed issue
No pre-existing conditions exclusions
No lifetime caps on coverage
Dependent coverage through age 26 (NY
requires dependent coverage through 30)
• Preventive care
• Women’s health care
Qualified Plan Benefits
Qualified plans must include:
Ambulatory patient services
Emergency room services
Maternity and newborn care
Mental health and substance use disorders
Prescription drugs
Qualified Plan Benefits continued
• Rehabilitative and rehabilitative services and
• Laboratory services
• Preventive and wellness services and chronic
disease management
• Pediatric services, including oral and vision
Metal Tiers
Plan tiers are based on the % of costs covered:
Bronze is 60%
Silver is 70%
Gold is 80%
Platinum is 90%
Deductible/Out-Of-Pocket Max
• Out-of-pocket maximum amounts may not
exceed established limits; adjusted annually.
• Deductibles generally can not exceed
established limits of $2,000/single or
Premium Assistance
• Individuals whose income is 139-400% of the
FPL may obtain a tax credit that can be
applied to the premium of any level plan
purchased in the exchange
• Employers with fewer than 25 FTE’s may earn
tax credits of up to 50% of premiums for 2014
and 2015 (35% for NFP employers)
• 2014: The greater of $95/adult & $47.50/child
up to $285/family or 1% of taxable income
• 2015: The greater of $325/adult &
$162.50/child up to $975/family or 2% of
taxable income
• 2016: The greater of $695/adult &
$347.50/child up to $2,085/family or 2.5% of
taxable income
NY Exchange Plans
Affinity Health Plan
Today’s Options of NY
BC/BS of Western NY
Capital District Physicians Health Plan
Emblem Health
Empire BC
Empire BC/BS
NY Exchange Plans continued
Fidelis Care
Health First
Health Republic
Independent Health
Market Plus
North Shore LIJ Care Connect
NY Exchange Plans continued
United Healthcare
United Healthcare Oxford
For More Information
• 1-855-355-5777
• www.healthbenefitexchange.ny.gov

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