With most of the Affordable Care Act’s major provisions now in effect, the nation’s health insurance marketplace has undergone a significant transformation. Obamacare impacts individuals, families and small business owners alike. Most Americans are required to have minimum essential coverage unless they qualify for an exemption; however, the law is designed to make health insurance more accessible and affordable with income-based financial assistance and one-stop shopping via state-based and federally facilitated exchanges. Meanwhile, the private marketplace remains a place to shop for quality, affordable health insurance plans that meet ACA requirements.
The following guide offers a glimpse at the various types of ACA-compliant health insurance in New York, including individual and family healthcare plans, small group health plans, coverage for high-risk applicants, mini-COBRA continuation coverage, Medicaid, and CHIP.
Health and healthcare in New York
New York ranked 14th in United Health Foundation’s 2014 America’s Health Rankings. Its strengths include low prevalences of obesity and smoking, high per capita public health funding, and ready availability of primary care physicians and dentists, while its challenges included a low rate of high school graduation, high percentage of children in poverty, and low immunization coverage among children.1
New York individual and family health insurance
When the Obamacare health insurance exchanges opened for 2014 enrollment, Florida defaulted to the federal health insurance marketplace, healthcare.gov. Individuals and families living in Florida may purchase health insurance coverage through the state’s federally facilitated exchange and in the private marketplace.
Those who buy health insurance through healthcare.gov may be eligible for income-based subsidies, including premium tax credits that may be applied to any metal plan and cost-sharing subsidies that apply to silver plans. Individuals who go without health insurance may face a tax penalty known as the shared responsibility payment.
The U.S. Department of Health and Human Services reported that 370,451 individuals in New York selected a marketplace plan through the exchange from Oct. 1, 2013, through April 19, 2014.2 In 2015, the number of individuals in New York enrolled in a marketplace plan increased to 408,841 during the open enrollment period.3
| New York health insurance exchange: | nystateofhealth.ny.gov |
| New York department of insurance: | New York Department of Financial Services—Insurance industry:dfs.ny.gov/insurance/dfs_insurance.htm |
New York small group health insurance plans
In New York, small businesses with 50 or fewer employees may purchase small group health insurance plans through the federally facilitated Small Business Health Options Program, SHOP Marketplace, at healthcare.gov/marketplace/shop and in the private marketplace. Small businesses that use SHOP and have 25 or fewer employees may qualify for a Small Business Healthcare Tax Credit.
Self-employed individuals with no employees must apply for an individual health insurance plan on or away from healthcare.gov.
| New York health insurance exchange: | Employers | nystateofhealth.ny.gov/employerEmployees |nystateofhealth.ny.gov/individual/employee_landing |
Self-employed individuals with no employees must apply for an individual health insurance plan on or away from the New York State of Health exchange.
New York state COBRA variations for small groups
The Consolidated Omnibus Reconciliation Act (COBRA) allows those employed by businesses with 20 or more employees to continue their group health insurance plan for a limited time should they lose coverage due to qualifying events such as termination of employment due to reasons other than gross misconduct, a reduction in work hours, divorce or legal separation, and loss of dependency status. To learn more about the federal COBRA program, visit dol.gov/ebsa/cobra.html.
In some states, those who work for a small business and lose health insurance coverage due to a qualifying event may qualify for health insurance continuation through mini-COBRA programs. State mini-COBRA programs allow those who work for a small business and lose health insurance coverage due to a qualifying event to continue coverage, too. These programs generally work like the federal COBRA continuation coverage, but their terms may vary. New York’s small group COBRA continuation variations are as follows:7
| Mini-COBRA option | Yes (New York State’s continuation coverage law) |
| Eligible group sizes | Employers with fewer than 20 employees | Employers with 20 or more employees* |
| Maximum continuation period – standard | 36 months |
| Maximum premium increase | Individuals who elect continuation coverage may be up responsible for up to 102 percent of their premium cost (premium cost plus administrative fees) |
| State legislation reference | Chapter 498 of the Laws of 2009 |
| More Information | 212-480-6400 or 800-342-3736 (New York Department of Financial Services’ Consumer Assistance Unit) |
| Additional notes | * Those who are not eligible for 36 months of federal COBRA continuation coverage may be eligible for New York continuation coverage to a total of 36 months. |
New York high-risk pools
It used to be that health insurance companies could deny applicants or charge them more based on health history and preexisting conditions. When the Affordable Care Act was passed in 2010, many states created federally funded preexisting condition insurance programs or accepted federal funding to assist with similar high-risk pool programs they already operated.5
The Affordable Care Act prohibits this practice for health insurance plans considered minimum essential coverage with effective dates beginning Jan. 1, 2014, and later. As such, the PCIPS and state high-risk pools created to provide health insurance for those once considered uninsurable are being phased out.
New York Medicaid
Medicaid is a state health insurance program for low-income individuals under age 65, pregnant women, children, disabled individuals, and seniors over age 65; it is partially funded by the federal government. In 2014, states were given the option to accept additional federal funding and expand their Medicaid program eligibility to those who make up to 138 percent of the federal poverty level.
The information below is specific to New York Medicaid program.
| Medicaid expansion | Yes |
| Governing agency | Centers for Medicare & Medicaid |
| Administrator | New York State Department of Health |
| Where to apply | nystateofhealth.ny.govRead about additional application options athealth.ny.gov/health_care/medicaid/#apply |
| Medicaid helpline | 800-541-2831 |
| Residency requirements | New York resident, U.S. citizen, qualified non-citizens |
| Eligibility | You may be eligible if your income is low and you:6Have high medical bills, Receive Supplemental Security Income, Meet certain financial requirements |
| More information | DCF health.ny.gov/health_care/medicaid/ |
| Open-enrollment period | Year-round in all states |
New York CHIP
The Children’s Health Insurance Program is a partnership between the states and federal government. CHIP provides health insurance to uninsured children who meet certain eligibility guidelines. The information below is specific to New York’s CHIP program.
| Program name | Child Health Plus |
| Website | health.ny.gov/health_care/child_health_plus/ |
| Where to apply | nystateofhealth.ny.gov | In-person application locations may be found athealth.ny.gov/health_care/child_health_plus/where_do_i_apply.htm |
| Phone number | 800-698-4KIDS (800-698-4543) |
| Eligibility | Low-income, uninsured children under 19 who are residents of New York State |
1 United Health Foundation. 2014 America’s Health Rankings Annual Edition. “Annual State Health Rankings.” http://www.americashealthrankings.org
2 Kaiser Family Foundation http://kff.org/other/state-indicator/state-marketplace-statistics-2014/.
3 Kaiser Family Foundation http://kff.org/other/state-indicator/state-marketplace-statistics-2015/.
4 New York State Department of Financial Services. “COBRA and Premium Assistance.” Last revised Jan. 8, 2014. Retrieved from http://www.dfs.ny.gov/consumer/cobra/cobra_prem.htm.
5 National Conference of State Legislators. Coverage of Uninsurable Pre-Existing Conditions: State and Federal High-Risk Pools. Updated April 2014. Retrieved from http://www.ncsl.org/research/health/high-risk-pools-for-health-coverage.aspx
6 New York State Department of Health. “Medicaid in New York State.” health.ny.gov. Retrieved from http://www.health.ny.gov/health_care/medicaid/.