You can shop for a health insurance plan on the NY State of Health, the Official Health Plan Marketplace. Private health insurance plans pay for a portion of the care and services you receive. They contract with a group (network) of doctors, clinics, hospitals and pharmacies to provide this care at agreed upon prices. It’s important to choose the health insurance plan that’s right for you.
EInsurers are limited in how they can make their plans different. Qualified Health Plans can differ in three main ways:
- Services Covered (Benefits)
- Delivery of Care (such as provider network)
- Cost (including monthly premiums and how much you have to pay when you get care)
All plans cover the same 10 benefits, including hospital care, prescription drugs, and doctor visits. Some insurers offer “non-standard” plans, which have additional benefits or substitute certain services for others.
- Check to see if the plan covers your medications on its preferred drug list.
- Do you want benefits beyond the 10 benefits offered by all plans? Examples include dental care and acupuncture. If you do, you can check to see which non-standard plans offer the benefits you need. You can also consider plans that offer only dental coverage.
Each plan will have a different provider network. You can save on health care costs by getting services only from providers in your plan’s network. Some plans may require you to choose a doctor to be your Primary Care Provider (PCP).
- Ask doctors you regularly see for the names of plans sold in the NY State of Health that they accept.
- Look at the plan’s network to see if it has doctors, hospitals, and clinics near where you live or work.
- Consider the type of plan. HMO and EPO plans only pay for care provided by in-network doctors.
- Review the state’s consumer guide to health insruance to find out how insurers compare on quality of care, complaints reveiced, and appeals and grievances. Information on new insurers is not currently available but will be included in future guides. To access the current guide, visit: www.dfs.ny.gove/consumer/hgintro.htm
All plans have 2 types of costs: the monthly cost that you pay up front (premium) and the cost you pay when you get services (out-of-pocket-costs). Out of pocket costs include things like deductibles, copays and coinsurance. Make sure to look at both types of cost when you consider which plan is affordable for you.
- Think about how much you can afford to pay each month for coverage.
- Think about how often you will need health care services and how much you will have to pay for these services. Does the plan have a deductible (the amount you will have to pay before the plan pays for services)? What are the copays (the set amount you will have to pay for services like a doctor’s visit)?
All plans are divded into four cost-sharing levels, called metal levels. The metal levels describe how the cost of care is usually split between you and the health plan. This includes the premium and out-of-pocket costs.
- Platinum: You pay 10% / Plan pays 90%
- Gold: You pay 20% / Plan pays 80%
- Silver: You pay 30% / Plan pays 70%
- Bronze: You pay 40% / Plan pays 60%
Each plan
Note: Each plan charges a different premium for the coverage it offers. Usually, the higher the premium, the lower your out-of-pocket costs will be. Platinum plans have the highest premiums and the lowest out-of-pocket costs. Bronze plans will have the lowest premiums and the highest out-of-pockets costs. All plans limit the total amount of your cost-sharing each year (your “out-of-pocket maximum”).
You may be eligible for financial help to lower your monthly premium cost and/or your out-of-pockets costs. If you are eligible for cost-sharing reduction (lower out-of-pocket costs) and enroll in a Silver plan, you will pay less for your care.
Young adults (under 30 years old) and people who cannot find affordable coverage may enroll in a Catastrophic plan.
You must pay your first premium within 10 days of receiving your bill. Your coverage will end if you do not pay your monthly premiums.