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How to Choose a Plan

Whether you are a small business owner, sole proprietor or individual buying insurance on your own, here are some things to think about as you select a plan.

Public Health Insurance

If you qualify for Public Health Insurance (Medicaid or Child Health Plus) you can enroll all year long.
  • If you and your family meet the income levels, you may qualify for free or low-cost public health insurance. As of 2014, the NY State of Health Marketplace is the only place most people under age 65 can go to get public coverage.
  • You will need to select a health plan.  Health plans pay for your care.  They work with a group (network) of doctors, clinics, hospitals and pharmacies.  You will choose one of the doctors from the health plan to be your Primary Care Provider (PCP). You will go to your PCP and the other doctors in the plan for your care.
  • All Medicaid managed care plans are free, meaning you do not pay a monthly premium. Child Health Plus plans are free or have a monthly income, depending on household income. All plans cover the same health care services.  But they are not all the same:
    • They can have different doctor and hospital networks
    • They can cover different prescription drugs
    • They can have different quality and patient satisfaction ratings
For additional information on selecting a Medicaid Managed Care Plan click here.

For tips on selecting a Child Health Plus Plan, click here.


Private Health Insurance/Qualified Health Plans (QHP)

Whether you are a small business owner, sole proprietor or individual buying insurance on your own, here are some things to think about as you select a plan.

Click below to learn more about your health plan options:
For quick tips on selecting a Qualified Health Plan, click here.

All plans offer the same basic benefits
 All new plans sold to individuals and small businesses – both inside and outside of NY State of Health – will include these 10 “essential” health benefit categories:

  1. Ambulatory care 
  2. Emergency services 
  3. Hospitalization
  4. Maternity and newborn care 
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs 
  7. Rehabilitative and habilitative services and devices 
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management 
  10. Pediatric services, including oral and vision care
In addition, the plans will be very standardized – meaning the benefits and cost-sharing will be largely the same, based on New York State requirements for “standard plans”. Click here to see what the benefits will look like in all standard plans.
  • Insurers may also offer a few “non-standard” plans. These plans include the same 10 essential health benefits, but they can differ from standard plans in one or more of the following ways:
  1. Non-standard plans can change the cost sharing required in any benefit category,
  2. Non-standard plans can add benefits to one of the 10 essential health benefit categories,
  3. Non-standard plans can add benefits that are not considered essential health benefits, such as dental care for adults
  4. Non-standard plans can substitute specific services for those required to be included in standard plans- but only in the following two benefit categories: (1) Preventive/Wellness/Chronic Disease Management, and (2) Rehabilitative and Habilitative care
Note: “Grandfathered” plans (plans purchased before March 23, 2010 that haven't been changed much), large group plans, and self-insured plans (usually offered by large employers) do not have to cover these benefits.

You can choose from 4 levels of coverage or "Metal Tiers"

 All new plans will offer one of four levels of categories, described as “metal tiers”:
  1. Platinum
  2. Gold
  3. Silver
  4. Bronze
As noted above, for the most part, the benefits are the same in each of these tiers. It is how the cost of care is split between you and the plan that makes health plans in one metal tier level different from those in another metal tier.
You can also think of it this way: the different tiers describe how “generous” the plan is – meaning, how much the plan typically pays toward the cost of a covered benefit when you use it.
The more the plan pays, the less you usually pay out of your own pocket when you get health care, as follows:

  1. Platinum tiered plans: on average, individuals in platinum plans will pay for about 10% of their total medical costs, in addition to their monthly premiums. The plan will pay about 90% of medical bills.
  2. Gold tiered plans: on average, individuals will pay for about 20% of their total medical costs, in addition to their monthly premiums. The plan will pay about 80% of medical bills.
  3. Silver tiered plans: on average, individuals will pay about 30% of their total medical costs, in addition to their monthly premiums. The plan will pay about 70% of medical bills.
  4. Bronze tiered plans: on average, individuals will pay about 40% of their total medical costs in addition to their monthly premiums. The plan will pay about 60% of medical bills.
No matter what metal tier level you (or your employees choose, if you are a small business and you offer them a choice of plans), there will be a limit to how much you will have to pay out-of-pocket on medical care each year. The maximum you will have to pay out-of-pocket is $6,350 for an individual and $12,700 for a family in 2014.
It is important to know that all of these limits and levels of coverage only apply to services that are covered by your health plan and provided by “in-network” facilities and doctors.

  • In-network doctors have agreements with the health plan about the fees they will charge to people enrolled in the plan. If you go to a doctor out-of-network, the plan will pay a smaller portion of what it usually does for that service – making you pay more of the cost of the care.
  • The out-of-network doctor may also charge a higher fee than an in-network doctor would charge or what is considered usual, and the doctor can require you to pay that difference. Asking the patient to pay the difference between what the health plan allows and the doctor charges is called “balance billing”.
  • In-network doctors cannot do this, but out-of-network ones can.

Learn more about finding in-network doctors and NY’s new protections against “surprise” out-of-network bills.

Pick a plan that meets your needs
No matter what plan you pick, the benefits will be the same or very similar. But that doesn’t mean all of the plans will meet your health care needs and budget.  
As you compare plans, think about what is important to you in a health plan:

  • The doctors and hospitals that you can see may be different with each plan, so check the provider network to be sure your doctor is included in the plan’s network.
    • If a doctor is not included in the plan, does the plan provide any “out-of-network” benefits? If so, check to see how much more it will cost you if you go to a doctor out of network.
  • Look at the quality ratings and reviews from people who already have a plan offered by that insurer. Some insurers are new in 2014, so they won’t have these ratings yet.
  • Think about your budget and health care needs: 
    • How much can you pay each month to have health insurance? 
      • If you are an employer, think about how much your employees can afford to pay and look into ways to help them save money by offering a Section 125 Premium Only Plan.
  • What do you expect your health care needs to be this year?
    • Do you or your employees expect to have a lot of medical needs, like having a baby or knee surgery?
  • What if something unexpected happens? How much can you afford to pay for care if you have an accident or get cancer?
  • Think about your total budget, the care you will need, and what protection you want from unexpected health care costs. In general:
    • Buying a plan that is more “generous” – like a platinum plan - will usually cost you more each month in premiums, but you will pay less when you go to the doctor
  • If you don’t go to the doctor much, it may make sense to buy a “less generous” plan and put aside money in case something unexpected happens and you need more care than you thought you would.
NY State of Health has unique benefits

While all health plans offer similar benefits inside and outside of the Marketplace, they may differ in terms of their provider networks and quality ratings, as discussed above.
There are also certain benefits that are only available in NY State of Health:
  • For small businesses, the main benefit is a tax credit available to very small employers. You can also give your employees a choice of plans. To read more about these benefits, click here.
  • For individuals and self-employed workers,
    • NY State of Health is the only place you can get premium tax credits and cost-sharing reductions to lower your private health insurance costs.
To read more about these benefits, click here.

Get help for free from a certified professional
  • For small businesses:
    • Agents and brokers are available to help small businesses evaluate potential costs and assist you in your selection process. Those who are certified by the state can also help you buy insurance through NY State of Health’s SHOP.
    • Navigators and other in-person assistors certified by the state can also help you purchase plans in the SHOP.
    • To find someone to help you with SHOP insurance, visit 
    • To find someone to help with insurance outside of the SHOP, you can search for a broker in your area through the National Association of Health Underwriters website at 
  • For individuals, sole proprietors and self-employed workers
    • Navigators and other in-person assistors who are certified by the state can help you get insurance in NY State of Health. Brokers and agents may also be able to help you.
    • To find someone to help you with insurance outside of NY State of Health, contact health insurers directly.


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Finding an in-network doctor

Check with your insurer to find out which providers and hospitals participate in your specific health plan.  Different plans can have different provider networks, even if they are offered by the same insurance company.

Most insurers post links to their provider networks on their website.  You can also call the plan and ask about whether a specific doctor or facility participates in your plan’s network. 

Since these lists can change, be sure and call the doctor or hospital directly to make sure he or she is still participating in the plan before you make an appointment.  When you know you will be admitted for an inpatient procedure, request that all of the doctors and specialists who are scheduled to care for you participate in your plan’s network.

Coming soon:  better information about your provider network
Starting April 1, 2015, more information will be available to help you know who is in your plan’s network:
  • Insurers must keep up-to-date lists on their website. Any changes to the providers in a plan’s network must be made within 15 days.
  • Providers must tell you if they participate in your plan’s network.  If they refer you to specialist, they have to tell you if the specialist is in your network, too.
New protections from “surprise bills”
Starting April 1, 2015, you won’t have to pay extra if you received care from a provider outside of your network because you had a medical emergency or through no fault of your own.  

More details about how these new protections will work will be provided in the future, but here are a few FAQs based on what is known now:

Q:  What if I have a medical emergency? 

You will only have to pay your usual copayments, coinsurance or deductibles when you receive care for an emergency, even if the care is provided by an out-of-network provider.  Out-of-network provider will only be able to bill your insurer only, and a third party will handle any disputes between the provider and insurer – you don’t need to get involved.

Q:  What if I need care that’s not available in my plan’s network?

If your insurer’s network does not provide a service or include a type of provider you need, you can request pre-authorize from the insurer to see an out-of-network provider.  Once you get your insurer’s approval, you and the provider must complete an “assignment of benefits” form.  The provider will then bill your insurer, not you, for payment.

Note:  the service you request must be covered by hour health plan. If your insurer denies your out-on-network request for a covered service, you will be able to dispute this decision through the state’s external review system

Q:  What if my doctor sends me to an out-of-network doctor? 

Your in-network provider will have to refer you to other in-network providers.  If you must see an out-of-network provider out of necessity, the referring provider must notify you in writing that the referral is to a non-participating provider and that you may incur additional costs not covered by your health plan. If you are not properly informed that the referral is to an out-of-network provider, you will not be held responsible for additional costs (except for your usual copayments, coinsurance or deductibles). The out-of-network provider must bill your insurer only.  Any disputes between provider and insurer will be resolved by an independent arbiter.

Q: What protections do I have now?

There are many protections already in place for health insurance consumers.  Learn more about your rights and how to file a complaint here.


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