QUESTIONS & ANSWERS

NY STATE OF HEALTH ENROLLMENT WEBINAR

DECEMBER 12, 2018

QUESTIONS & ANSWERS

ELIGIBILITY & ENROLLMENT

What information do

I need to have when

I’m ready to start my

application?

We ask about income and other information about you

to tell you what coverage you qualify for and if you can

get help paying for it. We keep all the information you

provide private, as required by law. If you plan to apply

for financial assistance to help pay for your coverage,

it is helpful to have the following information available:

• Social Security numbers (or document numbers for

legal immigrants who need health insurance)

• Birth dates

• Employer and income information for everyone in

your family

• paystubs from the last 30 days

• for self-employed individuals, recent

tax returns or profit and loss statements

• Policy numbers for any current health insurance

• Information about any job-related health insurance

available to your family

• List of current doctors (to verify plan participation)

The Marketplace uses Modified Adjusted Gross

Income (MAGI) to determine eligibility for financial

assistance. MAGI includes income from employment,

as well as any other form of taxable income. It also

includes other sources of income that may or may

not be taxable, such as social security benefits,

some foreign income, and tax-exempt interest. The

Marketplace application has a drop-down menu to

help you determine which types of income to include.

Assets are not considered in the determination of

eligibility for financial assistance for Marketplace

plans.

The application asks for your projected income for

2019. Eligibility for financial assistance is based on

your income for the year that you have that coverage.

You should go ahead and apply. When you no longer

need coverage, you can cancel your Marketplace

coverage. You should notify NY State of Health

when you want to cancel your coverage. We ask that

individuals provide 14-days notice when cancelling

their coverage.

Consumers can enroll in Qualified Health Plan

coverage during the annual Open Enrollment Period

and in certain circumstances outside of open

enrollment if they have a qualifying life event. Open

enrollment for 2019 is November 1, 2018 through

January 31, 2019. The deadlines to enroll are:

• December 15, 2018 for coverage

beginning January 1, 2019

• January 15, 2019 for coverage

beginning February 1, 2019

• January 31, 2019 for coverage

beginning March 1, 2019

Eligible consumers can enroll in Medicaid, the Essential

Plan, and Child Health Plus at any time during the year.

What types of income

are considered when

applying for financial

assistance?

I’m applying for coverage

for 2019. Should I use

my 2018 income or my

2019 income on the

application?

I expect to only need

coverage for 6 months.

Should I still apply?

What are the enrollment

deadlines and when will

coverage begin?

The income eligibility levels vary by program. To

qualify for Medicaid, an individual can earn up to

$16,754 a year and a family of four can earn up to

$34,638 a year. For Essential Plan coverage with no

monthly premium, an individual can earn up to $18,210

and a family of four can earn up to $36,900. For

Essential Plan coverage with a $20 monthly premium,

an individual can earn up to $24,280 and a family of

four can earn up to $50,200. To qualify for advance

payment of the premium tax credits when enrolling in

a Qualified Health Plan, an individual can earn up to

$48,560 and a family of four can make up to $100,400.

Federal rules require that you file taxes to be eligible

for tax credits. This is because tax credits are

determined based on an estimate of your income

but must be reconciled at year end to your actual

income when you file your federal income taxes. This

structure allows you to receive tax credits in advance,

instead of waiting until tax time, to get help paying for

coverage.

If you do not file your taxes or fail to reconcile the tax

credits received, you will not be eligible for tax credits

for the following plan year. You can still enroll in a

plan during the Open Enrollment Period but you will

not be eligible for financial assistance. When you file

your taxes from the previous year, your eligibility for

financial assistance can be redetermined at that time.

Assistors are available to help with this process.

What are the income

guidelines for various

Marketplace programs?

Can I continue to

receive federal financial

assistance (tax credits)

if I didn’t file taxes last

year?

When you “age off” of your parents’ coverage, you

may be eligible to enroll in through the Marketplace.

You will need to apply for coverage within 60 days of

turning 26.

When I turn 26 I will no

longer be covered by my

parents’ health insurance

plan. What are my

options?

Yes, in many cases you can stay on your parents’

health plan until you turn 26. (The requirement that

insurers offer coverage to children through age 26 on

a parent’s plan applies to insured products, but not

self-funded plans.)

If you decide to apply for coverage on your own,

eligibility for financial assistance is based on

household income and tax filing status. If a married

individual is not claimed as a dependent on anyone

else’s tax returns, he/she can apply for coverage

separately using his/her own income information,

regardless of whether all parties reside at the same

address. There can be multiple tax families living in

one house.

Yes. When it comes to estimating income, we

recommend you make your best estimate based on the

information you have at the time. Previous year tax

returns can help, as well as a thorough consideration

of upcoming changes in revenues and expenses

(e.g., a busy season, fewer anticipated clients, etc.).

We encourage you to update your income in your

Marketplace application throughout the year in order

to best reflect your financial circumstances and

eligibility for assistance. Further, providing accurate

and timely information to the Marketplace throughout

the coverage year can help mitigate any discrepancy

that may occur when you reconcile tax credits

received on your federal income taxes.

I am a 25-year old

married adult residing

with my parents. Can

I stay on my parents’

health plan?

Can self-employed

individuals and

freelancers with income

that fluctuates during

the year enroll through

the Marketplace?

Yes. The NY State of Health website homepage

(www.nystateofhealth.ny.gov) includes the link to a

premium estimator tool. Click the orange button that

says, “View Plans and Estimate Your Costs.” You will be

prompted to enter your zip code to see plans available

in your county. You can narrow your search further by

selecting to search by coverage tier, insurer, county,

type of coverage, metal level, and quality rating. You

can also “estimate financial help” by entering your

household size and income. Your search criteria will

generate a list of plans that are available in your

county and display the monthly premium before and

after any tax credits you may be eligible for.

Is there a way to

estimate how much

financial assistance I’m

eligible for?

Generally, no. However, there are certain instances in

which a change in insurers is permitted. For example,

if you are eligible for a different program type entirely,

(e.g., your eligibility changes from Qualified Health

Plan to Medicaid or Essential Plan), or are enrolled and

become newly eligible or ineligible for tax credits, you

will be permitted to select a new health insurance plan

during the year. In most cases though, you can only

change insurers during the annual open enrollment/

renewal period.

There are two types of renewal: automatic and

manual. When you get to the end of the NY State

of Health application, you will be asked to select

one type. If you select automatic renewal, the

Marketplace will re-determine your eligibility by

checking various state and federal data sources and

let you know what you qualify for in the next year.

(If we are unable to re-determine your eligibility for

any reason, we will notify you.) If you select manual

renewal, you will need to update your information

and complete the application without the automated

process facilitated by the Marketplace.

Consumers can always update their accounts and/or

provide documentation if circumstances are different

from what is determined by the Marketplace.

All enrolled individuals will receive a notice 30-days

in advance of the enrollment deadline with

instructions for renewal. Regardless of renewal type,

NYSOH recommends that all consumers login to their

account to confirm the details of coverage for the

upcoming year.

Can I switch plans at

any time throughout the

year?

Can you describe the

annual renewal process?

Children over the age of 19 are not eligible for

coverage through Child Health Plus. Depending on

tax filing status and income, adult children may be

eligible for Medicaid, the Essential Plan, or a Qualified

Health Plan.

Consumers have a wide range of plans to choose from

in 2019 across the state. There are 12 insurers offering

Qualified Health Plan coverage and 16 insurers

offering Essential Plan coverage in 2019. On average,

consumers have a choice of 4 Qualified Health Plan

insurer options in every county and a choice of 4

Essential Plan insurer options in every county.

The Essential Plan is available to eligible consumers

based on age and income. Generally, individuals

between the ages of 19-64 with incomes between

138%-200% of the Federal Poverty Level ($16,754-

$24,280) are eligible for the Essential Plan. If your

income is above 200% ($24,280 for an individual) of

the Federal Poverty Level, you are likely eligible to

enroll in a Qualified Health Plan. Most consumers

under the age of 65 can enroll in a Qualified Health

Plan on the Marketplace and, depending on income,

may be eligible for a tax credits that could help lower

the cost of coverage.

The Essential Plan and all Qualified Health Plans

offered on the Marketplace have the same

comprehensive essential health benefits package.

The Essential Plan has a monthly premium of either

$20 or $0 depending on income, and there are no

out of pocket costs for consumers. Qualified Health

Plans vary in terms of monthly premiums, deductibles

and out of pocket costs, whether you are eligible for

financial assistance, the metal level of coverage that

you choose (platinum, gold, silver, or bronze), and

insurer options vary depending on where you live.

What are the coverage

options for adult

children?

Do I have a choice of

Health Plans?

What is the difference

between a Qualified

Health Plan and the

Essential Plan?

COVERAGE OPTIONS

Monthly premium is amount that you pay to your

health plan to stay insured. Cost-sharing refers to

what you pay to use your insurance when you receive

services, such as a co-payment, co-insurance or a

deductible. Some plans don’t have any cost-sharing

requirements, such as Medicaid. The Essential Plan

has either low or no cost-sharing requirements for

enrollees, depending on income.

Cost-sharing for Qualified Health Plans depends

on the plan metal level, i.e. bronze, silver, gold,

or platinum. All metal level plans cover the same

essential health benefits, but vary in terms of

premium and cost-sharing requirements. In general,

bronze plans have the lowest premiums and the

platinum plans have the highest premiums. Bronze

plans typically have higher cost sharing in the form

of a deductible and copayment or coinsurance

requirements, while platinum plans have low or no

cost-sharing for enrollees. (Details are available here)

You should update your Marketplace account to

reflect the most recent information. For example, if

you weren’t working when you signed up for coverage,

but got a job a few months later, you should update

your account to accurately reflect that change in

income and employment status. Depending on the

type of coverage you have, changes to your account

may impact eligibility for financial assistance or

increase or decrease the level of financial assistance

you currently receive.

What do the terms

monthly premium, cost-

sharing and deductible

mean?

What if I have a life

change event during

the calendar year that

changes my household

size, tax filing status,

income or other

circumstances?

COST

There are three ways to get help completing your

application and enrolling in coverage:

Phone: NY State of Health Customer Service

Center (1-855-355-5777)

In Person: Visit a navigator, certified application

counselor or broker for in-person assistance.

(Find one here)

Web: Use the chat feature on our website to

help complete your application, available during

customer service center hours.

No. Assistance is provided free of charge. Assistors

are available in your community, work flexible hours,

and speak multiple languages. Assistors are available

to help you complete your application, understand

your health insurance options, and to help you make

the best choice for enrollment.

The NYS Provider & Health Plan Look-Up tool is

available on the NY State of Health website home

page (purple button). This tool allows you to search

by health plan or by provider or facility name to see

which providers participate with which health plans.

The tool also has advanced search options (e.g.,

language spoken, wheelchair accessibility). The tool

is updated with information sent to New York State

directly by health plans, but we recommend that you

confirm network participation with your provider

directly to be certain before enrolling in a plan.

Can I get assistance

enrolling in NY State of

Health?

Do I have to pay for the

assistance I receive from

a Navigator or Broker?

How do I use the plan

provider look-up tool on

the NYSOH website?

APPLICATION & ENROLLMENT ASSISTANCE

PROVIDER NETWORK

Most people who are eligible for Medicare are ineligible

for Marketplace coverage because, under federal

rules, they already have what is considered “minimum

essential coverage.” However, there are limited

exceptions, including those for parent caretakers. An

in-person assistor or Customer Service can help you

determine if you are eligible for Marketplace coverage.

You may cancel your COBRA and enroll in a Qualified

Health Plan during Open Enrollment. If it is outside

of Open Enrollment, you must wait until your COBRA

benefits are exhausted, at which point you would

be eligible to enroll through the Marketplace with a

Special Enrollment Period (due to loss of minimum

essential coverage). You will have 60 days to sign up

for coverage after your COBRA coverage ends.

If you are enrolled in COBRA and are eligible for

Medicaid or the Essential Plan, however, you can

cancel your COBRA at any time and enroll in those

programs through the Marketplace.

Yes. Most children are eligible to enroll in Child Health

Plus, and may be eligible for financial assistance

depending on household income. The spouse/

domestic partner is also eligible to enroll through

the Marketplace; however, eligibility for financial

assistance will depend upon whether the employer

sponsored insurance is considered affordable under

federal rules.

If I am eligible for or

enrolled in Medicare,

can I enroll in Qualified

Health Plans or the

Essential Plan through

the Marketplace?

If I am currently enrolled

in COBRA, can I cancel

my coverage and enroll

in coverage through the

Marketplace?

If only one person

in a family is offered

coverage from their

employer, can the rest of

the family enroll through

the Marketplace?

OTHER COVERAGE

Yes. Under these circumstances, you are likely eligible

to decline the employer sponsored coverage and

apply for financial assistance to enroll in coverage

through the Marketplace. In general, if the cost of

employer sponsored coverage is more than 9.86% of

your income, it is considered unaffordable. If the cost

is not more than 9.86% however, you can still decline

the coverage and enroll through the Marketplace. You

would not be eligible for financial assistance, but you

may have more plans and cost sharing arrangements

to choose from that may better suit your needs.

There is a section of the application that can help

you determine whether the coverage offered by your

employer passes this “affordability test.” You can

also contact the Human Resources office or benefits

administrator at your place of employment, and

they should be able to tell you whether the offered

coverage passes the ACA’s affordability test.

What if my employer

offers me individual

coverage at a cost

of $900/month and

my annual salary is

$50,000? Can I buy

insurance through NY

State of Health instead?