health insurance

A New Yorker’s Guide to Enrolling in Obamacare for 2015

POMPANO BEACH, FL - APRIL 20: Emlyn Louis, MD speaks with Julia Herrera as he examines her at the Broward Community & Family Health Center on April 20, 2009 in Pompano Beach, Florida. Mr. Louis's job was saved when the American Recovery and Reinvestment Act provided funds for community health centers. The Broward Community & Family Health Centers received nearly $1.5 million in Recovery Act funds, allowing them to halt layoffs and instead hire 13 additional employees. In total, the funds will provide services for an additional 6,600 underserved South Floridians while saving or creating 15 local jobs. (Photo by Joe Raedle/Getty Images) *** Local Caption *** Emlyn Louis;Julia Herrera
Photo: Joe Raedle/Getty Images

It’s that time of year again: The second open enrollment season for Obamacare — or as we call it ‘round these parts, New York State of Health — begins on Saturday. While the political drama continues (the Supreme Court just agreed to hear a case that could deal a major blow to the Affordable Care Act), the new exchange is working out pretty well in New York, which is one of the 14 states that chose to offer its own marketplace rather than relying on the federal site A recent poll found that 92 percent of New Yorkers who signed up last year are satisfied with their coverage. That’s good news, because if you currently lack health insurance and don’t sign up for 2015 coverage between November 15 and February 15, you will be taxed 2 percent of your income, all the way up to $975, if you make more than $10,000 a year.

Before you start checking out your options, there are some important changes to New York’s marketplace that you should know about. No more Freelancers Union coverage! No more out-of-network plans! But, thankfully, significant subsidies if you make below certain amounts! So, just like last year, we checked in with Elisabeth Benjamin at Community Service Society, one of many local nonprofits paid by the federal government to help people navigate their way through the sea of new options. This Q&A should get you up to speed (and if you want to geek out, here’s an early peek at the monthly premiums for the 2015 plans and detailed info on all your coverage options, county by county).

Hi, Elisabeth! What’s the state of health care in New York State?
Our exchange is doing great. New York had anticipated enrolling a million people in three years, but the exchange enrolled 1.5 million in its first year alone. This time around, New York City specifically will be offering 11 different plans, each with different “metals,” or pricing tiers: platinum, gold, silver, and bronze.

What if you’re happy with the plan you signed up for last year?
If you do nothing, you’ll stay enrolled in it, but your prices will go up. Plans should’ve notified members already of the price hikes, which on average are 5 percent — New York’s lowest hike in years. But it’s a good idea to look at the new options; you might find something cheaper or more to your liking. I urge people to find a navigator like us to walk them through their options, especially if you have complicated self-employed income. If your adjusted income after taxes is below $46,680 as an individual, $52,920 as a married couple, or $95,400 as a family with kids, your premiums could end up lower than half the sticker price. I had someone paying $60 a month on a $460 premium. You can calculate your subsidy here. Put in your adjusted income, not your gross!

What else is new?
It’s going to be easier to compare plans this year because the menu will distinguish between standard plans, with fixed co-pays for all drugs and services, and nonstandard plans, which make you pay co-insurance, or a percentage of the raw cost, on some drugs and services. Every carrier has to offer at least one standard plan.

How much will the plans cost in 2015?
For individual plans in New York City, platinum plans (highest premiums but lowest deductibles, maximum out-of-pocket costs, and co-pays/co-insurance) range between $515 and $1,095 a month; gold plans are $449 to $928; silver plans are $391 to $785; and bronze plans (lowest premiums but highest deductibles, maximum out-of-pocket costs, and co-pays/co-insurance) are $315 to $657. There are also bare-bones catastrophic plans from $150 to $349. Married couples without children can double those rates, married couples with kids can multiply them by 2.85, and single parents with kids can multiply them by 1.7.

What if you need to go to the ER out of state?
Some of the Empire plans have multistate coverage. [Editor’s note: We checked; some plans offer coverage that could cap an out-of-state ER visit at around $200, but they also tend to have mystery-fee co-insurances rather than fixed co-pays.] Overall, travel insurance is your best bet — or expatriate coverage for an extended stay.

What about dental coverage?
Dental is only included in the medical plans for kids. Otherwise, you’ll be asked when you sign up if you want separate dental, and there are going to be many new plans in NYC. Prices aren’t out yet, but they shouldn’t be much more than they were this year: $11 a month average, with $36 co-pays per visit, no deductible.

So no more Freelancers Union insurance — what’s that about?
Yeah, the Freelancers Union is sending out notices telling people they’ll be auto-enrolled in an Empire plan that FU has picked for them. But prudent folks should shop the marketplace, because low- and middle-income freelancers are in a great position to get premium subsidies, which FU’s Empire plan doesn’t offer. Again, use the tax-credit calculator. If you’re grossing $60,000 but it goes down to $30,000 after expenses, you can get hundreds a month off your premiums. Also, other plans might have more doctors and services offered than the default Empire plan.

Why is FU dropping their health care?
New York State no longer requires individual plans to offer out-of-network coverage, and carriers don’t want to, saying that doctors then have no incentive to join their networks, hence prices go up for everyone. Their point may be true.

What should people who’d planned on getting coverage with out-of-network options do?
You need to shop wisely. Make a list of the high-priority doctors and specialists you might already have and see which plans they’re taking. Also, make a God-forbid list. If you get cancer, do you want to go to Memorial Sloan Kettering or NYU or Beth Israel? On a related note, if you have special meds, check plans’ formularies (drug lists) and co-pays for those drugs. Again, feel free to call a navigator. It can be really nice to sit down with someone and go through these complicated options.

Editor’s note: New York is one of 27 states that have expanded Medicaid, so residents may qualify if they make less than $16,000 per year. Under the Affordable Care Act, undocumented immigrants can’t participate in the exchanges, but they can start here to access health care through the city hospital system and various community health centers.

A New Yorker’s Guide to Obamacare for 2015