As everyone knows, the Affordable Care Act (ACA or otherwise known as “Obamacare”) has had a negative impact on small (and even some large) businesses with respect to group health insurance options for employees. As time goes on, more and more employees are finding the coverage they have through their jobs is not as good as it used to be.

Perhaps you’ve noticed some of the negative changes yourself: increased deductibles/co-pays/coinsurance, decreasing employer contribution of premiums, doctors not accepting your health plan…sound familiar? All of these changes are a direct result of how your employer is responding to the increased cost of health insurance due to the passage of Obamacare. Remember in New York State, if a small employer (2-50 employees) has a group health plan in place for the senior staff, it must be made available to all employees of the company. However, small employers are currently not required by NYS law to pay the employee premiums for group health coverage.

Individual Market Coverage Alternatives

The good news is, the ACA has introduced a new individual health insurance market, which has created a new way for NY residents to secure health insurance for themselves, and without having to go through their employer’s to get it. This can give individuals more control over their health care in a number of ways including:

-Being able to select a plan whose doctors are all in the network

-Being able to select a plan structure specific to their financial needs, as opposed to being stuck with what their employer is offering them

-Being able to take their health plans with them should they decide to change jobs

Premium Payment Assistance

In addition to employees being able to secure their own health insurance via the individual market, they may also be able to receive tax credits to help pay their premiums, and possibly even their policy deductibles. It all depends on whether or not they meet tax credit subsidy eligibility requirements, as established by the NYS Department of Health.

For employees who are considering waiving employer-sponsored coverage in lieu of securing individual health insurance with tax credit assistance, here are some important things to know:

-Tax household gross incomes must be between 400% and 133% of the Federal Poverty Level (FPL) to be eligible to receive tax credits (maximum income of $45,960 for a single tax filing, or $94,200 for a tax filing of four)

-Tax households with a gross income under 133% of the FPL are considered Medicaid eligible, and will not qualify for tax credit assistance for individual health insurance plans. Though individuals may choose to opt out of Medicaid for an individual health plan if they wish, they must pay the full price of the plan

This is of utmost importance: Employees who are offered Essential Health Benefits through their employers, but who turn it down in lieu of getting their own individual plans with tax credit assistance, may only qualify for tax credits if their cost for employer-sponsored health insurance exceeds 9.5% of their gross annual income. If the cost for employer-sponsored health insurance is under 9.5% of their gross annual income, those employees will not qualify for tax credits, and will have to pay the full plan prices in the individual market (which still could be a better option for some employees)

How to Enroll In Individual Market Health Insurance

-Unless someone experiences a qualifying life event, individuals may only secure a plan during the open enrollment season (November 15 2014, through February 15 2015)

Contact a licensed insurance broker who is certified to write individual health plans both with and without tax credit assistance. They will be able to recommend plan options for you and your family

-For individuals who need tax credit assistance, individual market enrollments are conducted on the NY State of Health exchange website. Your broker will drive the entire online enrollment process for you

-For individuals who are not tax credit eligible, individual market enrollments are conducted using traditional paper applications (1-2 pages). Your broker will provide you with applications, and will forward them to the carrier on your behalf

*Important Notes*

-Individual market health insurance is not government health insurance. The only role the government plays in securing individual health insurance is handing out tax credits for those who qualify. Otherwise, it is a private relationship between the individual and the insurance company

-Certified insurance brokers will be listed in the NYSOH broker directory. Be sure the licensed broker you are working with appears in this directory

-For tax credit NYSOH on-exchange enrollments, do not confuse licensed insurance brokers with “Navigators” or “in person assistors”. Navigators are not Federally required to be licensed to write health insurance, which means they are not allowed to make plan recommendations for you, nor are they subject to criminal background checks in most states. They are merely government contractors (paid for with federal government grant money) to help individuals meet their tax obligations under the ACA law (individuals must enroll in coverage or they will be subject to fines). Unlicensed Navigators are not appointed by any health insurance companies, which means they will have no access to carrier-specific plan materials, benefit summaries, provider network information, nor can they write you with a policy directly with an insurance company

-Certified insurance brokers do not charge broker fees, nor are they paid by the government to help individuals enroll in coverage. They are private professionals, and are paid commissions on the back end by the insurance company. These commissions are built-in to an individual’s monthly premium, whether a broker is used or not. If no broker is appointed by the individual, the insurance company retains the commission. As such, it’s in your best interest to always work with a licensed broker to help you secure your individual health insurance, since you’ll be paying for the service either way

The 2015 individual market open enrollment season is rapidly approaching. For more information about securing individual coverage for you and your family, contact an insurance broker.