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10 Essential Tips for Getting Coverage Under the Affordable Care Act

By Amy Zimmer | September 30, 2013 6:55am
New Yorkers Sound Off on ObamaCare
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Dnainfo/Heather Holland, Serena Solomon, Janet Upadhye

MANHATTAN — Figuring out the best health insurance plan is enough to make anyone's head spin.

So, there will likely be a lot of questions come Oct. 1, when some 1.5 million uninsured New York City residents can start shopping for health coverage under the Affordable Care Act, better known as Obamacare.

And while many details have already been set in stone — including the companies that will offer benefits to New Yorkers and the range of monthly premium costs — the key details that matter most to consumers won't be revealed until the New York Health Benefit Exchange goes live Tuesday, including which doctors and prescription drugs are in-network and what the deductibles and co-pays will be.

 Images from Oscar's website.
The new insurance company Oscar
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"Nobody really enjoys thinking about insurance," said Elisabeth Benjamin, vice president of health initiatives of the Community Service Society, which is one of more than 20 nonprofits and community agencies the state tapped to act as "navigators" to help guide people through the process.

"But the point is there will be a lot of discounts,” she said, urging New Yorkers to visit the online marketplace and check out their options.

DNAinfo New York has rounded up a list of some of the most common questions about the Affordable Health Care Act.

1. How much will it cost?

Approved rates for the four tiers of plans range from the bronze level (where insurance covers 60 percent of costs) offered by newcomer Health Republic Insurance of New York at $311.77 a month,  to the platinum plan (insurance covers 90 percent) offered by United at $913.99 a month.

Many people, however, won't have to pay these prices, Benjamin said.

"Three-quarters of people will be eligible for some sort of financial aid," she said, noting that prices were already roughly half the rates private insurance companies have been offering.

"What's amazing about this: Look at these numbers," she said. "This is 53 percent cheaper on average than what you can get on market today."

2. Who qualifies for financial aid?

Some 75 percent of New Yorkers are expected to qualify for reduced-cost insurance purchased through the exchange. Anyone whose household income is less than 400 percent of the federal poverty level (which would be less than $45,960 for an individual and $94,200 for a family of four) would be able to get federal tax credits to offset the full monthly price.

The "New York State of Health" website has a tax credit and premium estimator where families can plug in their income to figure out their rates.

Someone with an annual income of $17,000, for example, will only have to pay $55 a month for a silver level, or a family of four with an income of $35,000 will pay $114 a month, explained Heidi Siegfried, director of health policy with the Center for Independence of the Disabled of New York, one of the navigators.

People with incomes up to 250 percent of the federal poverty level — $28,725 a year for a single person, $47,100 for a family of four — will also get financial assistance with co-pays and deductibles, she said.

3. Who is eligible to buy insurance on the exchange?

The exchange is designed primarily to fill the void for those who don’t have insurance or who have coverage that costs too much.

If you already have health insurance through your employer, you can keep what you have. You can switch to one of the plans on the exchange — and qualify for discounts — only under the following conditions: If you're paying more than 9.5 percent of your income for coverage, or if you have coverage that isn't considered comprehensive  — meaning insurance is paying less than 60 percent of the total accumulated costs. Also, you will be eligible to qualify for financial aid.

Others who have insurance through work can also buy plans on the exchange, but they won't be able to get any tax credits.

"You get the benefit of the price reduction of bulk purchase," Benjamin noted. "You just can't get the financial aid."

4. Can the uninsured opt out of coverage?

Skipping coverage won't be free: For the first year, it's $95 per adult or 1 percent of taxable family income — whichever is greater. In 2015 it will jump to $325 per adult or 2 percent of taxable income. The following year it rises to $695 or 2.5 percent of taxable income.

5. What will be covered?

The four tiers — bronze, silver, gold and platinum — all must cover “10 essential health benefits,” including doctor’s visits and hospital stays, maternity and newborn care, mental health and substance abuse services, and preventative and wellness services. Some plans will offer dental and vision coverage, too.

6. Is very basic, cheap coverage available?

Some companies are offering catastrophic coverage, which will be the cheapest plans because they will have high deductibles. The lowest rate will be offered by another newcomer to the field, North Shore-Long Island Jewish, at $183.53 a month. Those subscribing to these plans, however, won't qualify for financial aid.

These plans are only options for consumers under the age of 30 or if someone qualifies for a “hardship exemption," Benjamin said.

7. What health insurance companies will offer coverage in New York City?

Roughly a dozen companies — all carefully vetted by the state — will be offering plans on the New York Health Benefits Exchange.

While many of the companies may have familiar names, like Empire Blue Cross and Emblem Health, there are a couple of newbies trying to challenge the typical insurance business model.

Health Republic is a nonprofit co-op where the majority of board members will be consumers, and Oscar is a tech-savvy company launched by three young Harvard Business School grads.

The company — whose interface has a Facebook-like timeline for medical history — has an engineer from Tumblr and designers from Google.  Consumers will be able to have virtual visits or calls with doctors.

"You can have a bright, articulate doctor call you in 30 minutes without using a dating site," co-founder Kevin Nazemi, 32, joked.

Health Republic's president Debra Friedman said her company offers the lowest premiums in many categories.

"We don’t have any stock analysts where there are expectations of meeting margin requirements," she said. "We have members deciding how money should be reinvested in the plan."

8. When will coverage take effect?

Coverage is expected to kick in Jan. 1, 2014 for anyone who enrolls before Dec. 15 — barring any delay from Washington. (The 15th of the month is the cut-off for the following month.) Open enrollment will last through March 31. You will only be able to sign up after the six-month window closes because of certain life events, like the loss of a job, birth, marriage or a divorce.

9. What about people with pre-existing conditions?

Starting next year, health insurance companies — on and off the exchange — cannot discriminate against individuals with pre-existing conditions by charging more or denying coverage, according to officials.

10. Where can I get help picking a plan?

Navigators will set up shop at libraries, food pantries and other spots across the city for one-on-one sessions. Appointments can be scheduled via phone (1-888-614-5400) or through CSSny.org or the NY State of Health site. There will also be a customer service center (1-855-355-5777) for those with questions.