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Navigating the Affordable Care Act in New York State

Posted on 13 November 2013

Alice Yaker, director of community outreach for New York State of Health, shares information about the Affordable Care Act at the Rogers Memorial Library in Southampton on November 7. (Michael Heller photo).

Alice Yaker, director of community outreach for New York State of Health, shares information about the Affordable Care Act at the Rogers Memorial Library in Southampton on November 7. (Michael Heller photo).

By Annette Hinkle

While the roll-out of the federal government’s health insurance exchange program continues to be stuck in a quagmire of missteps and a botched website, New Yorkers should experience far fewer frustrations when they go to sign up for health coverage.

That’s because New York is one of just a handful of states which took the initiative to create their own healthcare marketplaces and websites as part of the Affordable Care Act — and according to Alice Yaker, director of community outreach for the New York Department of Health, things in New York are working pretty well so far.

“Some states did not develop their own marketplace and in those states, the federal government has developed it,” explained Yaker. “New York has developed its own marketplace to best meet the needs of New Yorkers.”

“All the marketplaces all over the U.S. opened on October 1 — some more successfully than others,” added Yaker who noted that as of October 23, 174,000 people had completed applications on the state’s website,

“What that means is 174,000 people came to the website, completed the application and were deemed eligible, but had not yet selected a health plan or had contact with the insurer they selected.”

“Of that 174,000, a little over 37,000 are fully enrolled,” she added. “We are doing pretty well.”

Yaker gave two presentations last week at Southampton’s Rogers Memorial Library about New York State of Health, the official health plan marketplace for those seeking coverage in the state.

Yaker said currently there are 2.7 million New Yorkers under the age of 65 who are uninsured. The goal of the marketplace is to enroll 1.1 million of them in a health insurance program within three years — either Medicaid or a private health plan — through the New York State of Health online marketplace.

“The range of people who can go into the marketplace is broad,” explained Yaker, “an individual in the state who is here legally or a small business with 50 or fewer employees, you can go for a private plan, qualified health plan or public insurance. You may be Medicaid or CHP [Child Health Plus] eligible, you may be eligible for financial subsidies or you may be eligible for no subsidies at all.”

“Everyone will go through the same web portal to shop, compare and enroll,” she added.

Yaker admits small businesses aren’t likely to see a reduction in health insurance premiums for their employees as a result of the Affordable Care Act. However, the big boon, she notes, will be for individuals purchasing their own coverage.

“Right now, individual premiums are expensive — $1,500 to $2,000 a month,” she said. “It’s a tremendous difference in cost with the marketplace where premiums are an average of 53 percent lower than it is right now — and 75 percent of individuals who we will work to enroll will be eligible for financial subsides.”

“Lower premiums and the availability of subsidies will increase that market enormously,” she said.

The first round of open enrollment in the marketplace runs through March 31, 2014. Insurance policies will begin kicking in on January 1, 2014 and individuals must be enrolled in a plan by December 15 for it to take effect on the first of the year.

“For people eligible for Medicaid or CHP, they can enroll at any time,” she said. “Those with a qualifying event — loss of job, loss of insurance — you can enroll outside open enrollment.”

For many, the most daunting aspect of the healthcare marketplace is navigating the website and choosing a plan. For that reason, Yaker advises the use of trained navigators and in-person assisters who can walk applicants through the process. Some navigators are insurance brokers, who will earn a commission on whatever plan you select, others are certified application counselors who work for organizations like hospitals and health centers, but all, she noted, have been trained to help consumers pick a plan that best suits their needs.

“Suffolk has a number of navigators available to sit down with you during the application process,” she said. “They’re a really good resource and funded by the federal government. They can help individuals and small businesses.”

New York State of Health has a list of navigator agencies throughout Suffolk County on its website — the nearest one being at Southampton Hospital.

“Make an appointment, sit down and go through the process,” said Yaker who encourages people to start by applying on line. “You can stop the process and come back to it at any time. You’ll get an identification number, so you don’t have to complete the application at that time.”

While there are 16 qualified health plans available across all of New York State through the marketplace, only eight of them provide coverage within Suffolk County: Affinity, EmblemHealth, Empire Blue Cross Blue Shield, Fidelis Care, Health Republic Insurance, North Shore LIJ, Oscar Insurance Corporation and United Healthcare.

“The more plans there are in your county, the better the choices you have,” said Yaker. “Some smaller counties upstate have fewer plans available to them.”

All of the insurance providers must offer coverage in four “metal tier” plans — bronze, silver, gold and platinum. The difference in the plans is the percent of medical costs paid by the insurer versus the insured.

“With a bronze plan, 60 percent of costs will be paid by the insurer and you’re responsible for 40 percent,” said Yaker. “But the premium is lower than the premium for the platinum plan, where 90 percent of costs are paid for by the insurer and you pay 10 percent.”

“The silver plan is a 70/30 split and for gold, it’s 80/20,” said Yaker who added that there may be higher fees and copays associated with a bronze plan and cautioned that selecting a plan is about assessing risk.

“Do I anticipate I’m not going to have many medical costs? Do I not have any chronic illnesses? Do I want the lower premium of a bronze plan with the hope I won’t have many out of pocket costs?” she asked. “Or do I know my medical costs tend to be consistently high? In that case, I might look at a gold or platinum plan where the insurer pays a larger percentage of costs.”

“You need to weigh that,” she said.

While the Affordable Care Act requires insurers to offer a minimum of 10 essential benefits across the country (including maternity and mental health/substance abuse coverage), states have the right to add others and in New York, insurance plans must also cover chiropractic care. Some health plans also come with dental. But for those that don’t, Yaker notes there are 12 qualified dental plans available which can be added as stand alone coverage.

“One of the things navigators and in-person assisters will do is compare the benefits available, the premiums described for each health plan and the provider networks to enable you to really compare which ones are right for you,” she said. “Different health plans have different networks — which works best? Where are your doctors? Your hospitals? You want to see the costs, the coverage, the copays so you don’t have to do it on your own.”

“That’s the point I want to get across,” she added. “Go on the website and play with it.”


Three ways to get through the process.

-       Online — fill in the application on the website. If you have a question, there is a web chat option and someone can answer questions and continue to move you through the process.

-       By phone — there’s a special number to help in the enrollment process. 1-855-355-5777 from 8 a.m. to 8 p.m. M-F and 9 a.m. to 1 p.m. on Saturdays. They can take applications in 10 different languages and there’s a separate language line for others.

-       In person in your community — through navigators, brokers and certified application counselors who sit with you across the desk and walk you through the process by shopping and comparing.


Looking for more information?

To find Insurance companies offering plans in the State of New York

(Includes Name, toll-free telephone numbers and linked websites)


1) On the home page, click on “resources” and a list of links appears.  Scroll down to Health Plan Provider Networks.

2) You will scroll down and see a link health: Health Plan Provider Networks.pdf – click on that and you will receive the chart of insurance companies that have been approved for New York State to be part of the insurance exchange.

3) It will be in a table format – you can print it out.  THIS WILL BE FOR ALL OF NEW YORK STATE.


While there are 16 health providers available across the state, only eight of them will provide coverage within Suffolk County: Affinity, EmblemHealth, Empire Blue Cross Blue Shield, Fidelis Care, Health Republic Insurance, North Shore LIJ, Oscar Insurance Corporation and United Healthcare. Here is information for them:


Affinity1-866-247-5678  EmblemHealth1-800-223-1831  Empire Blue Cross/ Empire Blue Cross Blue Shield1-800-385-2036

NOTE:  Not available for Bronze plans

Fidelis Care1-888-343-3547  Health Republic Insurance (NY CO-OP)1-888-990-5702  North Shore LIJ1-855-706-7545 
Oscar Insurance  United Healthcare1-877-856-2429 


To find a list of tax credits for health plans and a premium estimator:

To use this calculator, you will need Microsoft Excel software – you will also need to know  your annual taxable income for 2012.


1)     Click on the Resource page.   Tax Credit and Premium Estimator link is listed first.

2)    Click on:  Tax Credit and Premium Estimator.  You will need to have Microsoft Excel for this calculator to work.

3)    Scroll down on that web page you and you will see this link:  Tax Credit and Premium Estimator  – CLICK on that.

4)    It will NOT appear on your screen – it automatically downloads onto your computer.  (For Apple computers, to access recently downloaded files, it appears in the upper right hand corner as a downward arrow; for PC computers, go to where your downloaded files are kept.

5)    A pop-up box appears, choose “enable macros” and a working excel chart will appear.

6)    Fill out the calculator – AFTER putting in your taxable annual income, click on the next white box.

7)    Drop down menus appear – the first box, click on the down arrow of the drop down box and choose which level of insurance you want (Bronze, Silver, Gold, Platinum or Catastrophic.  (Catastrophic is only available to a restrictive young age level)

8)    The next box, click on the down arrow of the drop down box and select Suffolk (County)


Scroll down and the estimator will tell you

1)     Which insurance companies are available to choose from

2)    What your premium is estimated to be

3)    If you are eligible for a tax credit (which you can choose when you apply to have immediately deducted from your monthly premium expense OR take as a tax credit when you do your taxes).

4)    Your premium amount after the tax credit is applied.


To find a schedule of benefits for Bronze, Silver, Gold and Platinum Insurance Plans


1)     From the Resource page, go to the search line (in the grey bar) and type in STANDARD PRODUCTS.

2)    Scroll down and click on: Covered Benefits and Out-of-Pocket Costs for Standard Health Plans

3)    Scroll down – click on: Standard Products.pdf

4)    Each level of insurance (Bronze, Silver, Gold and Platinum) will be listed with Deductibles, Out of Pocket Limits, what is covered in full and what co-insurance is covered after your deductible has been met.  Each level of coverage is 5 pages – starting with Bronze coverage.



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