Health Insurance Options for Sole Proprietors
NYS Health Benefit Exchange: Open Enrollment Starts October 2013 • What Can Sole Props Get Now? • Healthy NY for Sole Props and Small Businesses • Potential Group Coverage Options for Sole Props • Individual Market • Public Health Insurance Presentation Outline
NYS Health Benefit Exchange: Open Enrollment Starts October 2013
NY Individual ExchangeChanges in 2014 • In 2014, sole proprietors will no longer have access to New York’s small group market • Sole proprietors may get coverage through the New York State Health Benefit Individual Exchange • Exchanges are online marketplaces like “Orbitz” with an interface like “Turbo Tax”
NY Individual ExchangeEnrollment • Initial open enrollment starts October 1, 2013 and ends March 31, 2014 • Coverage begins January 1, 2014 • Special enrollment periods will be available during the year for certain circumstances • Those eligible for Medicaid or Child Health Plus can apply at any time • Annual open enrollment will start on October 15 and end on December 7 for the 2015 benefit period and beyond
NY Individual ExchangeLowering Prices • Insurance works best when healthy people have coverage! • Individual mandate, tax subsidies, and the Exchange work together to drive down prices • Premium prices in the individual market are expected to be reduced by 66% • Exchange mechanisms • Large marketplace to shop for coverage • Big purchasing pool increases buying power and reduces administrative costs • Private insurance plans will compete • Buyers can compare plans apples-to-apples
NY Individual ExchangeTax Subsidies and Annual Out-of-Pocket Maximums • Sole proprietors may be able to receive tax subsidies and cost sharing reductions on Individual Exchange • Tax subsidies available for individuals with income up to 400% of the Federal Poverty Level (FPL) • 400% FPL in 2013 for an individual is $45,960/year • 400% FPL in 2013 for a family of four is $94,200/year • Exchange plans have annual maximum out-of-pocket limits. • Calculate your potential subsidy and maximum costs: • http://healthreform.kff.org/subsidycalculator.aspx
What Can Sole Props Get Now?
Healthy NY for Sole Props and Small Businesses(This program sunsets in 2014)
Healthy New YorkSole Proprietor Eligibility • New York State residence • Ineligible for Medicare • Applicant or spouse employed now or within last year • Employer does not provide health insurance • 12-month wait after voluntarily dropping private coverage • Income below 250% of FPL • $2,327/month (individual) / $3,977/mo (family of 3) • Sole Props can deduct documented business expenses from income
Healthy New YorkSmall Business Eligibility • Business located in NY State • 1-50 eligible employees • At least 30% of employees earn $40K or less • No group health insurance in last 12 months • 50% of the eligible employees will participate • Employer contributes at least 50% of premium • Must be offered to all employees working 20+ hours per week and earning $40K or less
Healthy New YorkBenefits and Cost • High deductible for new enrollees • $1,250 (individual) / $2,500 (family) • Covers most medical services, with copays • Drug Coverage optional • EXCLUSIONS: Mental Health; Substance Abuse; Chiropractor; Hospice; Ambulance; Vision; Dental; DME • Can exclude pre-existing conditions • If applicant uninsured more than 62 days (two months) • $250-$500/month for one person. Prices vary by plan and county.
Healthy New YorkProgram Future • Healthy NY program will conclude for individuals and sole proprietors on December 31, 2013 • January 1, 2014 sole proprietors will be moved to the individual market • Small businesses with 2 – 50 will be transitioned to ACA compliant plans
Potential Group Coverage Options for Sole Props
FreelancersEligibility, Benefits, and Costs • Eligibility: • Independent Workers: freelance, sole prop, contractor, temp • Residency Requirements: NYC Metro Area through North Country, but not Central or Western NY • Work in Eligible Industry: Art, design, financial, etc. • Five different plans offered • Benefits vary by plan • Each plan has some deductible • HD plans have $5k and $10k deductibles • Individual coverage ranges from $225 to $603/month
Lose coverage due to a qualifying event • Lose job, hours reduced, divorce, death, age, etc. • Covered employer • COBRA: 20 or more employees • Mini-COBRA: 2 or more employees • Limited duration • COBRA: 18 months (or 29 or 36 months in some situations) • Mini-COBRA: 36 months • Must make COBRA election within 60 days • Benefits are the same as other members of the plan, including active workers • Cost is 102% of employer’s full premium cost COBRA (Federal) & mini-COBRA (State)Eligibility, Benefits, and Cost
Young AdultsDependent Coverage • New ACA “Age 26” Rule – Federal • Most plans must allow dependents under 26 to stay on parent’s plan, if they allow dependents at all • Must offer same pricing and benefits to all dependents, whether age 5 or age 25 • Can’t discriminate based on age “proxies” like student status, living at home, etc. • State – Age 29 Rule • Dependents under 30 can stay on parent’s plan • Dependent must pay full price of policy, like COBRA
Individual Market
Individual MarketEligibility • Guaranteed Issue • = • Everyone is eligible! • Regardless of age, health, gender, etc. • Some plans only offered in certain regions
Individual MarketBenefits and Costs • Prices and benefits vary by plan and county • Prices do NOT vary by applicant’s age, health • “Community Rating” • No plans under $1,000 in many counties • Prices by plan/county updated monthly at: • www.dfs.ny.gov/insurance/ihmoindx.htm
Individual MarketFinding Coverage • Independent Brokers • Experienced and knowledgeable on plan designs • Enrollment assistance • NYC Health Insurance Link: nyc.gov/hilink • New York City coverage options • Web Interface to compare plans • Contact information to enroll directly with insurers • Healthcare.gov: finder.healthcare.gov • Web interface to compare plans • Contact information to enroll directly with insurers
Public Health Insurance:Medicaid, FHP, CHP, and Medicare
Public Health InsuranceMedicaid, FHP, CHP, and Medicare • Medicaid and Family Health Plus (FHP) • Free health benefits (nearly identical in both programs) for low income individuals and parents • Household income limit for single adults: $931/month • Household income limit for in a family of three: $2,387/month • Child Health Plus (CHP) • All kids are eligible! • Free coverage for low-income children • Sliding scale premium for higher incomes • Medicare • Coverage for individuals 65+ years old • Coverage for disabled individuals
Public Health InsuranceMedicaid, FHP, CHP, and Medicare • To find out more about public health insurance: • Call Community Health Advocates!! • 1-888-614-5400
Help For All New YorkersAssistance for Small Businesses and Consumers
More Resources • NY State Health Benefit Exchange: www.healthcarereform.ny.gov • Community Health Advocates: www.communityhealthadvocates.org • Hotline: (888)614-5400 • HHS Information: www.healthcare.gov • Health Care For All New York: www.hcfany.org • Congressional Budget Office: http://www.cbo.gov/publications/collections/health.cfm • Kaiser Family Foundation: http://healthreform.kff.org/ • Community Catalyst: http://www.communitycatalyst.org/ • ACA: www.healthcare.gov/law/full/index.html
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