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Affordable Care Act

In March 2010, President Obama signed comprehensive health reform – the Patient Protection and Affordable Care Act (ACA) – into law. This law is designed to make healthcare more affordable and accessible for all Americans.

As part of this law, most people without health insurance are required to obtain coverage or face a penalty.

New York State residents can purchase health insurance through the New York State of Health, the healthplan marketplace.

Health Coverage Requirements

Key Facts

Catholic Health services are covered by most insurance plans in the New York State of Health marketplace.

Be cautious when considering low-cost insurance products, as they often limit which physicians you can use and which services are covered. 

Know how much you are responsible to pay out-of-pocket for medical care and prescriptions. While some plans cap how much you are required to spend out-of-pocket, others do not.

Buying Health Coverage

Who & What Is Covered 

Small Business Owners

Click here for the Health Insurance Marketplace Small Business guide.

Don't see the answer to your question? Call us at (716) 601-3600 to speak to an expert.


Health Coverage Requirements

Am I required to have health insurance coverage?

As of January 1, 2014, most people are required to obtain basic health insurance coverage or face an annual penalty. To avoid a penalty, you will need minimum essential coverage.

If you are covered by any of the following, you are exempt from penalty:

  • Any marketplace plan or individual insurance plan you already have
  • Any employer-sponsored plan (including COBRA), with or without “grandfathered” status (including retiree plans)
  • Medicare
  • Medicaid
  • The Children's Health Insurance Program (CHIP)
  • TRICARE (for veterans and veteran families)
  • Veterans health care programs
  • Peace Corps Volunteer plans

You can enroll through your employer's health insurance program or through the New York State of Health marketplace.

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If I'm uninsured, will I have to pay a penalty?

If you are uninsured, you won't have to pay a penalty if you:

  • are uninsured for less than 3 months of the year
  • are determined to have very low income and coverage is considered unaffordable
  • are not required to file a tax return because your  income is too low
  • would qualify under the new income limits for Medicaid, but your state has chosen not to expand Medicaid eligibility
  • are a member of a federally recognized Indian tribe
  • participate in a healthcare sharing ministry
  • are a member of a recognized religious sect with religious objections to health insurance

If you live in New York State and are not eligible for Medicare, you will be able to purchase basic health coverage through the New York State of Health marketplace.

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What is the penalty for not having coverage?

The fee in 2014 is 1% of your yearly income or $95 per person for the year, whichever is higher. The fee for uninsured children is $47.50 per child. The most a family would have to pay in 2014 is $285.

The fee will increase every year. In 2016, it is 2.5% of your yearly income or $695 per person, whichever is higher.

If you decline health insurance coverage and choose to pay the fee, you will be responsible for 100% of the cost of your medical care.

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Buying Health Coverage

Who can buy insurance coverage?

In order to be eligible for health coverage through the New York State of Health marketplace, you must:

  • live in the United States
  • be a U.S. citizen or national
  • not be currently incarcerated

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If I have coverage through my employer, can I still shop in the New York State of Health marketplace?

If you currently have health insurance, you may use the New York State of Health marketplace to explore your options. 

However, before you can buy insurance through the marketplace, you would need to cancel your employer coverage first and follow their enrollment/disenrollment guidelines. You may have to wait until the end of the policy year before you can cancel the policy.

If you have a qualifying life event, such as a job loss, birth, or divorce, or if you lose your coverage, you may be able to shop for coverage in the marketplace during a special enrollment period.

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How much does it cost? Will I qualify for financial assistance?

You can compare plan choices based on price, provider network, or quality score by visiting the New York State of Health marketplace.

You may be eligible for lower premiums based on your income and family size. Income/family size requirements for reduced premiums are:

  • Up to $45,960 for individuals
  • Up to $62,040 for a family of 2
  • Up to $78,120 for a family of 3
  • Up to $94,200 for a family of 4
  • Up to $110,280 for a family of 5
  • Up to $126,360 for a family of 6
  • Up to $142,440 for a family of 7
  • Up to $158,520 for a family of 8

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What types of plans are available in the New York State of Health marketplace?

There are four categories of insurance plans: Bronze, Silver, Gold, and Platinum. 

The category you choose affects how much your monthly premium will be and what you will have to pay out-of-pocket for your care. Generally, the lower cost plans have higher deductibles and co-payments, while the higher cost plans have lower co-pays and deductibles. 

For example, with a Gold plan, you'll likely have a higher monthly premium, but you will probably pay less when you go to the doctor or use another medical service than if you had a Bronze or Silver plan. With a Bronze plan, you'll have a lower monthly premium, but you'll pay more out-of-pocket when you receive medical care.

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How can I enroll?

Open enrollment closed on March 31, 2014.  For more information, visit the New York State of Health marketplace.

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Who can I talk to for more information?

There are several ways to get more information on the Affordable Care Act and the Insurance Marketplace.

On the web, visit www.healthcare.gov (Federal website) or the New York State of Health marketplace.

To speak to a live Catholic Health expert, call (716) (716) 601-3600.

To speak to a designated navigator in your county, call:

  • Erie County: Healthy Community Alliance, Inc. - (716) 532-1010
  • Cattaraugus County: Healthy Community Alliance, Inc. - (716) 532-1010, Southern Tier Healthcare System, Inc. - (716) 372-0614
  • Chautauqua County: Chautauqua Opportunities, Inc. - (716) 661-9430, Southern Tier Healthcare System, Inc. (716) 372-0614
  • Genesee, Niagara, Orleans, and Wyoming Counties: Lake Plains Community Care Network, Inc. - (585) 344-1692

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Who & What is Covered

What health benefits are covered?

The Affordable Care Act states that 10 essential health benefits must be covered in any small group or individual health plan. The benefits are broken down into the following categories of service:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventative and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

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Can I be denied coverage based on a pre-existing condition?

No, you cannot be denied coverage based on a pre-existing condition. Starting in 2014, health insurance plans cannot refuse to cover you or charge you more because you have a pre-existing condition.

Even if you have been turned down or refused coverage in the past, you cannot be denied. 

However, there is one exception. For "grandfathered" individual health plans (those purchased independently and not through your employer), coverage for pre-existing conditions can be denied.

Grandfathered plans are plans that were created on or before March 23, 2010 and have basically stayed the same. Even if you joined a plan after March 23, it may still be grandfathered – grandfather status is based on the date that the plan was created, not the date that you enrolled.

To learn if your plan is grandfathered, check your materials. Grandfathered plans must disclose this status in all materials describing plan benefits. 

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Can my adult children be covered on my plan?

All health insurance plans are required to cover adult children up to age 26. This applies, even if the child is:

  • married
  • not living with his or her parents
  • attending school
  • financially independent
  • eligible to enroll in his or her employer’s plan (with one exception for grandfathered plans)

Until 2014, grandfathered group plans that offer dependent coverage don’t have to offer it up to age 26 if a young adult is eligible for coverage through their own employer.

Grandfathered plans are plans that were created on or before March 23, 2010 and have basically stayed the same. Even if you joined a plan after March 23, it may still be grandfathered – grandfather status is based on the date that the plan was created, not the date that you enrolled.

To learn if your plan is grandfathered, check your materials. Grandfathered plans must disclose this status in all materials describing plan benefits. 

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Are Catholic Health services covered under my plan?

Most insurance plans in the New York State of Health marketplace cover services provided by Catholic Health and Catholic Medical Partners physicians.

However, low-cost products often have limited access to physician networks and healthcare services. If you are considering a low-cost option, please verify coverage with the insurance provider before enrolling. 

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Is preventative care free?

Unless your plan is a grandfathered plan, your plan will cover preventive screenings, like blood pressure and cholesterol tests, mammograms, colonoscopies, and more. Vaccines are also covered.

Health plans created or bought before March 23, 2010, which are known as grandfathered plans, are not required to offer full coverage. Check your plan’s materials or ask your employer or benefits administrator to find out if your health plan is grandfathered.

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How much am I expected to pay out-of-pocket?

Under the law, combined out-of-pocket spending on medical care and prescription drugs cannot exceed $6,350 a year for an individual or $12,700 a year for a family, including co-payments and deductibles, starting in 2014.

These spending caps will take effect for all health plans sold in the new insurance exchanges and health plans offered through employers whose medical and drug benefits are administered by the same entity.

The spending cap does not currently apply if:

  • your group health plan has separate administrators for medical services and prescription drug benefits. 
  • your prescription drug plan does not currently cap out-of-pocket spending. 

Spending caps in the above cases will go into effect in 2015.

See also: Obamacare Cap on Some Health Costs Delayed (August 14, 2013)

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Will I qualify for lower out-of-pocket costs?

Depending on your income, you may qualify for lower out-of-pocket costs that are not covered by insurance, such as medical deductibles and co-payments.

If your household income is below the following amounts, you will be eligible for lower out-of-pocket costs:

  • Up to $28,725 for individuals
  • Up to $38,775 for a family of 2
  • Up to $48,825 for a family of 3
  • Up to $58,875 for a family of 4
  • Up to $68,925 for a family of 5
  • Up to $78,975 for a family of 6
  • Up to $89,025 for a family of 7
  • Up to $99,075 for a family of 8

Plans are separated into four different categories: Bronze, Silver, Gold, and Platinum. If you qualify for out-of-pocket savings, you must choose a Silver plan to receive the savings.

Plans are explained in more detail at the New York State of Health marketplace.

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When does the new health coverage begin?

If you have enrolled in coverage through the New York State of Health marketplace by December 15, 2013, your coverage will begin on January 1, 2014.

Anytime after January 1, 2014, coverage will begin the first of each month, as long as you have enrolled by the 15th of the previous month.

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Small Business Owners

Do I have to offer insurance coverage to my employees?

While businesses are not required to provide insurance, large businesses may face a penalty in 2015 if insurance is not offered or is unaffordable for employees.

In January 2015, large businesses (those with more than 50 full-time employees) may be subject to a fee, called an Employer Shared Responsibility Payment, if: 

  • insurance is not offered,
  • an employee's share of the premium costs for employee-only coverage is more than 9.5% of their yearly household income,
  •  the plan covers less than 60% of the total allowed costs of benefits provided under the plan.

Businesses with 50 employees or fewer are not subject to the Employer Shared Responsibility Payment.

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If I don't offer insurance or the insurance does not meet minimum standards, what fee will I pay?

If you don't offer insurance or if your insurance does not meet minimum standards, businesses with more than 50 full-time employees will be subject to the Employer Shared Responsibility Payment.

  • If you don't offer insurance, the annual payment is $2,000 per full-time employee (excluding the first 30 employees).
  • If you do offer insurance, but the insurance doesn't meet the minimum requirements, the annual payment is $3,000 per full-time employee who qualifies for premium savings in the New York State of Health marketplace.

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What is the the Small Business Health Options Program (SHOP) Marketplace?

If you choose to offer insurance to your employees and have 50 or fewer full-time employees, you can use SHOP to offer coverage. Health coverage through SHOP starts as soon as January 1, 2014. 

Click here to visit SHOP.

If you have more than 50 full-time employees, you generally won't be able to use the SHOP Marketplace to offer health insurance to them. Starting in 2016, all SHOPs will be open to employers with up to 100 full-time employees.

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This information was compiled from a variety of resources, including HealthCare.gov and the New York State of Health marketplace. Please visit those sites for the latest news and information.

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