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Parent's advice to a child needing to enroll on NYS's health insurance exchange

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Dear Son who is aging out of coverage on our family health insurance:

I went to a health insurance seminar last night and got important info for you.

#1- The deadline is March 31 when open enrollment ends, which means unless you have a "life changing event" (birth, marriage, lost job, got a new job), you can't enroll again until the next open enrollment. Now, in your case, you will have a "life-changing event" - when you age out of our policy in July. STILL, YOU WOULD NEED TO REGISTER IN JUNE IN ORDER TO GET COVERED FOR JULY...

IT IS VITALLY IMPORTANT YOU DON'T LET INSURANCE LAPSE BECAUSE YOU WON'T GET IT UNTIL THE NEXT ENROLLMENT.

#2 Since you live in New York State, you must enroll at https://nystateofhealth.ny.gov/
This is the New York Exchange... (you don't go to healthcare.gov which is the federal site).

You will go to the section for Kings County.

You will see about a dozen different insurance companies who are participating in the NYS exchange - GHI isn't one of them. It turns out that GHI does not offer individual policies, so one way or another, you will have to choose a new policy.

Among the insurance companies that are participating are:

Emblem Health

Empire

Empire Bluecross Blue shield

Healthfirst

North Shore LIJ

Oscar

UnitedHealthCare,

UnitedHealthCareOxford

Fidelis Care

Excellus

(Apparently, Oscar, which no one had heard of before, is becoming the "hot" plan. But you must check them out.)

There are 4 different levels and they all basically have different premiums, deductibles and copays. SILVER IS PROBABLY THE BEST FOR YOU.

The different companies charge different prices BUT ALL OFFER THE SAME CARE because of Obamacare.

That means that all the policies, regardless of company or level must provide:

Preventive, wellness and chronic disease management

Inpatient care

Outpatient services

Mental health and substance abuse disorder services

THE DIFFERENCE IS THE HOSPITALS AND DOCTORS THAT PARTICIPATE IN THE THAT INSURANCE COMPANY plus the drugs they cover

This is vitally important that you call your local hospital and any doctors that you want to continue with and ask which insurance policies they accept.

Also the doctors and hospitals and drugs they cover can change during the year BUT YOU CAN'T CHANGE YOUR PROVIDER UNTIL THE ONE-YEAR ANNIVERSARY (OR OPEN ENROLLMENT AGAIN).

#3 I don't think you qualify for any tax credit but if you want to go for a tax credit, they will check with IRS and DMV to make sure you have listed your income accurately. I think you wouldn't qualify if you make more than $45,000 gross.

You can figure it out by going to the section in the site Info.nystateofhealth.ny.gov/premiumestimator

So, a single adult in Kings County earning $20K, would qualify for a tax credit of $280/month; so premiums start at $79/month.

The credit can be applied to the monthly premium payment, or taken in a lump sum at the end of the year.

#4 THE HEALTH PLANS DO NOT COVER DENTAL (YOU ARE GETTING THAT THROUGH GHI OR UFT, I BELIEVE) AND DOESN'T WORK OUTOFSTATE, BUT YOU SHOULD CHECK ON THIS - for example if you would relocate to San Francisco, you would be out of luck, unless that would qualify as a "life changing event (new job) and you could cancel a plan and get a new plan, but if you just visited san Francisco for a week or a month, you wouldn't have health coverage.

Check the provisions for emergency care out of state (I think none of the plans now work out of country, and that's why you buy travel insurance policy)

Here are estimated costs of the different levels of plan (catastrophic is not recommended and it is only for those making very little income)

All of the plans require you to use their IN NETWORK DOCTORS & HOSPITALS, so I repeat to say CALL YOUR LOCAL HOSPITALS AND CALL YOUR DOCTORS TO SEE WHAT THEY TAKE.

The Navigator who conducted the seminar gave some estimates for the different levels of premiums and coverage (but obviously, you would need to check these out specifically for the plan, and your geographical location, etc. etc.). But just to give an idea:

Platinum: zero deductible, $10 to see doctor, $15 for prescription, $40 for specialty drugs; specialist, $75. The premium averages $550

Gold - $600 deductible, $15/copy, $15 for prescriptions, $40 for specialty drugs, $75/specialist

Averages $450-475

Silver, $2000 deductible, $15/copay, $15 for prescriptions. Premium averages $350-400.

Bronze: assume a higher deductible, lower premium (there is a Bronze but she didn't provide the estimates, so you'll have to compare at the site.

One more thing: You don't have to buy through the health exchange. If you are really wealthy and want a more comprehensive plan you can just go to an insurance broker and buy something else.

But I am assuming you don't want to do that and you want basic coverage.

Obamacare Increased Access, But Still Problems with Health Care System

The plans are not perfect but Obamacare means that every policy has to provide certain things:

Wellness & preventive care
No exclusion for preconditions
No lifetime cap

And it was designed to be accessible (affordable) to the 40 million people who couldn't get or couldn't afford health insurance.

Otherwise, it did very little to correct the screwed up health care system we have.

It is unnecessarily complicated and dependent upon hospitals and doctors taking the plan - and that could be a real crisis. Because doctors and hospitals are balking at the rates of reimbursement the insurance companies are providing.

And there could be a real doctor shortage because if making health care accessible really works, that means that 40 million more people will be using the system. On the other hand, people will be healthier because they will have access to doctors who will be able to prevent or treat earlier so the ailment doesn't progress.

This is why the next phase of health care reform has to address how we produce doctors and nurses. So far, the medical industry has used monopolistic practices to control access to medical school and licensing in order to keep rates high. Hospitals, we are learning, are charging outrageous fees for some procedures and "pushing" procedures in order to boost their profits. And on the other hand, we are hearing of hospitals shutting down (Georgia, a state that refused to accept Obamacare and the federal funding that went with it, forcing millions to rely on expensive emergency care, just announced 8 closures.)

Most of us wanted a Single Payer plan (basically Medicare for all), and people could have gotten health insurance supplements (as Medicare recipients do), to cover the 20% gap and basically make access to any and every doctor and hospital that takes Medicare.

The Republicans made it plain they would not go for that, or even a public option, or even give people 55+ the opportunity to buy into Medicare.

So what I propose - if we can't get truly universal health care - is turning Medicare on its head: since 80% of medical costs are incurred in the last year of life, provide Medicare coverage from 0-65. Then, throughout that time, people can be socking money away in Health Savings Accounts. After 65, you can pay for the care you want and need out of your HSA. In this way, taxpayers aren't paying for $50,000 operations for an 85 year old to live perhaps three months longer; if the person or their children want the operation, they can pay for it.

In this way, people can live a productive, healthy and happy life.

In any case, one of the most important aspects of Obamacare is that it uncoupled the dependence on a job for access to health care by making it possible for individuals to access affordable health insurance through these exchanges.

That means that people are no longer kept captive in lousy jobs for fear of losing health insurance for themselves and their family.

And it means, like you, they can go off and start their own business.

Health Insurance for Small Businesses

Now, once you get your business underway (and you employ at least one person who is not a relative, you can qualify to get health insurance through the exchange and earn tax credits.

Here's what I learned about that:

Small business marketplace provides value for employers and employees.

New York State's goal is to enroll 110,000 small businesses covering 450,000 employees.

A key benefit for small business is that they can have a choice of three different insurance providers - their employees can choose the plan and choose the level of the plan they want. The employer can also choose a level of contribution - a percentage of the premium (for example, 50%), a percentage up to a fixed dollar amount (for example, 50% up to $300), or a fixed amount (for example, $300).

Then, the employer gets one bill from the state, and the state takes care of distributing the funds to the insurance providers (easier bookkeeping).

And then, the small business gets a health care tax credit- the fewer employees and the less they make (under $25,000), the greater the credit.

The maximum credit of 50% may be claimed by businesses with 10 or fewer employees with an average salary of $25,000 or less.

Once the company hits 25 employees, or they make $35,000, there is no tax credit.

As of this year, the marketplace is the only place to access tax credit (but a small business can get the tax credit retroactively to 2010).

Anyway, son, check out https://nystateofhealth.ny.gov/ or call the help line, 1.855.355.5777; (TTY: 1.800.662.1220), Monday - Friday, 8 a.m. - 8 p.m., Saturday, 9 a.m. - 1 p.m.

See also:

Despite Obamacare rollout, Progressives see single-payer health care as goal

Karen Rubin, Long Island Populist Examiner
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