Health Insurance Reform and the Affordable Care Act (ACA)
THIS DOCUMENT WAS CREATED AND MADE AVAILABLE BY GLENN MONES, EXECUTIVE DIRECTOR, NEW YORK CITY HEMOPHILIA CHAPTER (www.nyhemophilia.org).
Changes that have been made from the original version and any errors on this page are the responsibility of the Mary M. Gooley Hemophilia Center.
-- Frequently Asked Questions about Health Insurance, Health Insurance Reform and the Health Insurance Marketplace --
Which Health Insurance Coverage Should I Choose?
For people who live with a bleeding disorder (especially if they use clotting factor) health insurance is an important choice that should be made carefully. Factor is expensive and health insurance is essential. For people in New York State, health insurance options will fall into three main categories: public insurance through government programs (including Medicaid and Medicare), private insurance through an employer or private insurance purchased apart from an employer.
Medicaid is for some people who have little or no financial income (the Medicare program covers the elderly and those with disabilities). To obtain Medicaid coverage, one must qualify (be eligible based on income) and enroll. The Center can help with the Medicaid enrollment process. For people who have or can obtain health insurance coverage through an employer, the Affordable Care Act (ACA) may bring minimal or no changes – however, your employer can change the coverage they provide. For people without employer coverage (and who do not qualify for Medicaid or Medicare), new coverage will be available through a health insurance “Exchange” or “Marketplace.” People who have employer coverage may also choose to shop on the Exchange, looking for a better deal, for instance.
Necessary but expensive health care treatments (including clotting factor) present financial challenges and selecting health insurance coverage can be mystifying – what worked yesterday may not work today. Beware of enrolling in an insurance plan solely because premiums are low - you may discover later that coverage is limited. Even though its premiums may be high, an indemnity plan may be a good option if it will cover clotting factor. Even though its out-of-pocket costs may be high, a high-deductable health plan may be a good option if it will cover factor after the deductable is paid. Please review the rest of this document and contact the Center for help with questions.
What do Health Care Reform and the Affordable Care Act mean for me?
The Affordable Care Act (ACA), sometimes called Obamacare, is Federal legislation that substantially expands insurance coverage and protections for many Americans. Although some provisions of ACA are already in place, many more changes are coming in 2014. Below are examples of how these changes may benefit you or your family.
Exclusions from coverage for pre-existing medical conditions (i.e. a health condition you already had before you obtained the insurance) are no longer allowed. That means that a person with a bleeding disorder can no longer be denied coverage because of the bleeding disorder.
Plans will no longer be able to have lifetime or annual dollar limits on coverage for anything considered an “essential health benefit” (EHB) under Federal law. The 10 general essential health benefit categories required by law include: emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services; chronic disease management; pediatric services, including oral and vision care. We interpret these benefits to include all drugs and therapies for approved and generally used for the treatment of specific conditions, including bleeding disorders.
Young adults up to age 26 will be able to stay on their parent’s private insurance plan, even if they are married or don't live with their parents. After they turn 26, New York State law will allow some young adults to continue coverage through their parent’s plan up to age 30. These young adult coverage changes apply now to newly purchased plans. For existing plans, the changes will apply when the health plan policy is renewed.
A new range of coverage options will be available through an Exchange or Marketplace in each state. In New York State this marketplace is called New York State of Health. Enrollment in these plans will begin on October 1st, 2013, with coverage taking effect on January 1st, 2014.
What is the New York State of Health?
New York State of Health is now the official name for the Health Plan Marketplace or Exchange in the State of New York. These exchanges are designed to help people shop for and enroll in health insurance coverage. Individuals, families and small businesses will be able to use the Exchange to help them compare commercial insurance options, calculate costs and select coverage online, in person, over the phone or by mail. The Exchange will also help people to check their eligibility for health care programs like Medicaid and sign up for these programs if they are eligible. The Exchange will also be able to tell what type of financial assistance is available to applicants to help them afford health insurance purchased through the Exchange. Insurance coverage can be purchased through the Health Benefit Exchange beginning in October 2013 and will be effective January 1, 2014.
Is this coverage applicable to me?
Anyone who currently has adequate health insurance at an affordable cost (i.e. through an employer or government program) will probably want to continue on the coverage they already have. Folks who either do not have health insurance or who pay high premiums may want to explore enrolling in health coverage this fall through New York State of Health.
Please note that under the provisions of the Affordable Care Act, all families and individuals must have health insurance starting in 2014, and those who do not may be subject to penalties.
What insurance plans will be offered?
Twenty-one providers have been approved to offer Qualified Health Plans (QHPs) in New York State, but not all plans will be available in all areas. To see which plans will be offered in your area, go to http://www.nystateofhealth.ny.gov/resource/map-health-plans-offered-ny-state-health and click on your county. (Please note that this map was down recently for updating but should return shortly.
Each of these health insurance providers will offer Platinum, Gold, Silver, and Bronze plans as well as catastrophic plans with varying premiums, deductibles and levels of coverage. Plans will be available for individuals and families, and some providers will also offer plans for small businesses.
How much will the premiums be?
A preliminary list of what the monthly premiums will be for all Exchange plans in New York State is available at http://www.governor.ny.gov/assets/documents/Approved2014HealthInsuranceRates.pdf. Remember that not all of the listed plans will be available in your area, so use the links above to determine which ones will be available.
The premium you pay for health plans purchased through the Marketplace may be further reduced through a Federal subsidy if your household income is below 400 percent of the federal poverty level ($45,960 for individuals and $94,200 for a family of four). You can check your eligibility for this subsidy and see how much of a discount you may be eligible to receive using the Tax Credit and Premium Estimator found at http://www.healthbenefitexchange.ny.gov/resource/tax-credit-and-premium-estimator.
How do I know which plan is best for me or my family?
Selecting the right coverage is not always easy. The plan with the lowest premium is often not the best choice, especially when dealing with a high-cost conditions such as hemophilia and other bleeding disorders. It is more important to determine which plan will cover all of the things you and your family need for the lowest out-of-pocket cost.
The National Hemophilia Foundation (NHF) has a Personal Health Insurance Toolkit which can help you figure this out. You can download a copy of the Toolkit at http://www.hemophilia.org/NHFWeb/Resource/StaticPages/menu0/menu4/menu306/Toolkit.pdf. Printed copies will be available at the Mary M. Gooley Hemophilia Center at no charge.
The State of New York will be establishing Navigators who will assist individuals seeking to evaluate their options and enroll in a plan. A variety of community health organizations around the state will be designated as navigators. Assistance will be available on line, by telephone, and in person, depending on the organization and locale. More information about the navigator program and all aspects of the exchange are available on the New York State of Health website at www.nystateofhealth.ny.gov.
Additional information about options and resources in your area may also be available from the Mary M. Gooley Hemophilia Center on this website or by calling 585-922-5700
New York State Bleeding Disorders Coalition
The Mary M. Gooley Hemophilia Center is a member of the Coalition. The Coalition is a voluntary collaboration among Hemophilia Treatment Centers and Hemophilia patient organizations. It is dedicated to ensuring that people affected by bleeding disorders have access to quality health care, giving them the opportunity to live a full and active life. Visit the Coalition website at www.NYSBDCoalition.org
Coalition Who We Are
Cost and Comprehensive Care in New York
About Bleeding Disorders