What You Should Know About Getting Health Insurance

Open Enrollment on NY State of Health is here! If you’re thinking about getting health insurance coverage but find yourself confused about the different types of plans, when you can sign up, and other details, we’ve got the information you need.

December 09, 2016 | HF Healthy Living Team

In New York, NY State of Health is the marketplace designed to help people shop for and enroll in health insurance coverage. Individuals, families, and small businesses can use this marketplace to help them compare insurance options, calculate costs, and select coverage.

If you need health insurance, you may be looking for a plan right now. But what kind of plan is right for you? How much will it cost? And when should you sign up?

Don’t worry—we’ve got answers. Before you choose your coverage, here’s what you should know about getting health insurance.

Why Get Health Insurance, Anyway?

Even if you’re in good health, you should still get health insurance. Why? Because even healthy people need the medical and financial protections that health insurance offers.

Health insurance can help you:

  • Maintain or improve your health, or better manage a health condition, by covering regular doctor and specialist visits
  • Get access to free preventive care—like checkups, vaccines, screenings, and other tests
  • Get access to necessary treatment for illnesses or injuries
  • Stay protected from high medical costs, many of which can be unexpected

If you choose not to enroll into a health insurance plan, it means you will have to pay the penalty, or fee, that is assessed at your yearly tax filing. The fee is either a percentage of your household income or a per person amount—whichever is higher. For example, in 2016, the penalty is 2.5% of your total household income or $695 per adult and $347.50 per child under 18, with a maximum penalty of $2,085.

Types of Health Insurance Plans: HMO, PPO, EPO, and POS

Now that you know how important health insurance is, what type is best for you?

You may have seen these acronyms following the name of a specific health plan—HMO, PPO, EPO, and POS. In general, these acronyms refer to whether a plan encourages you to stay within their network, and whether you have to pay more if you seek care outside of the network.

A network is a list of providers—doctors, hospitals, and specialists—that a health insurance company is contracted with and offers to its members.

More specifically:

In an Exclusive Provider Organization (EPO) health plan, services are usually covered only if you see providers within the network. Typically, these plans are lower in cost but offer less flexibility than a POS or PPO. Typically, these plans are low-cost but offer the least flexibility.

In a Health Maintenance Organization (HMO) health plan, you usually need a referral from your primary care provider (PCP) to see a specialist, and there is often no coverage if you see providers outside of the network. Typically, these plans are lower in cost but offer less flexibility than a POS or PPO.

In a Point of Service (POS) health plan, you usually need a referral from your PCP to see a specialist, and there may be an additional cost if you see providers outside of the network. Typically, these plans offer more flexibility than an EPO or HMO.

In a Preferred Provider Organization (PPO) health plan, you usually do not need a referral from a PCP to see a specialist, but there may be an additional cost if you see providers outside of the network. Typically, these plans offer the most flexibility, but sometimes with higher costs.

Are you age 65 or above, or do you know someone who is? Do you have questions about Medicare? We’ve got answers to those questions here.

Essential Health Benefits

What kind of benefits do you get with a health insurance plan, anyway?

The Patient Protection and Affordable Care Act of 2010, sometimes called Obamacare, offers Americans a number of new healthcare rights and protections. For example, under Obamacare, health insurance companies can’t refuse coverage to those with pre-existing health conditions that an individual may have had prior to having health coverage.

Under Obamacare, all Qualified Health Plans on an individual state’s health insurance marketplace must cover certain services. These are called essential health benefits, and they include emergency services; prescription drugs; pregnancy, maternity, and newborn care; mental health; preventive services, and more.

You can see the full list of essential health benefits here.

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Other Important Benefits

While your health insurance plan must cover the essential health benefits you need to stay healthy, you may be looking for even more. Review your options carefully, as some health plans offer additional benefits such as:

  • Dental – some health plans might cover preventive services like dental checkups; or even more, like oral surgeries and periodontics
  • Vision – some health plans might cover eye exams and other eye screenings; or even more, like eyeglasses or contact lenses
  • Telemedicine – some health plans may offer you access to a doctor—any time of day or night, through video chat or phone—for prescriptions, to get help diagnosing and treating non-emergency conditions, and more
  • Acupuncture – some health plans may offer coverage for this ancient practice, an effective treatment option for pain and discomfort associated with a variety of illnesses and conditions

Healthcare Costs

Now that you have a better idea of the benefits available to you, you’re ready to pick a health plan. But how much will it cost?

In general, what you pay will depend on your income and number of dependents. If you’re shopping for health insurance on NY State of Health, you may notice that the health plans are divided into four categories: Bronze, Silver, Gold, and Platinum. These categories show how you and your health plan share costs; they’re not a rating of the health plan itself or an indication of the quality of care you may receive while covered under the plan.

  • Bronze – lowest monthly premium, but highest costs when you get care
  • Silver – modest monthly premium, modest costs when you get care
  • Gold – higher monthly premium, but lower costs when you get care
  • Platinum – highest monthly premium, but lowest costs when you get care

If you need help understanding certain health insurance words—like premium, copay, deductible, etc.—check out our glossary.

Open Enrollment Periods

Now that you know the different types of health insurance, what they cover, and how much they’ll cost, you’re ready to enroll! But when?

There are certain times during the year when eligible individuals may choose to keep their existing health insurance plan or enroll in a new one. These periods are called Open Enrollment Periods (OEP) or Annual Open Enrollment Periods. This time period varies by plan or program. Some plans allow enrollment all year.

The Open Enrollment Period for Qualified Health Plans on NY State of Health typically runs from November through January each year. You can check the specific dates here.

For coverage beginning January 1, 2017, you must sign up for a health plan no later than December 15, 2016.

The last day to enroll in a 2017 Qualified Health Plan is January 31, 2017. After this date, you can enroll or change plans only if you’ve had a Qualified or Qualifying Life Event (QLE). These events include birth of a child, marriage, loss of employment, loss of coverage, change in place of residence, and more. Learn more about Qualifying Life Events here.

If you live in New York and know you need health insurance for 2017, DON’T DELAY. Visit NY State of Health to learn more now.


© 2016 HF Management Services, LLC.

Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

This health information or program is for educational purposes only and not intended to treat, diagnose, or act as a substitute for medical advice from your provider. Consult your healthcare provider and always follow your healthcare provider’s instructions.

“Health insurance plan & network types: HMOs, PPOs, and more,” Healthcare.gov. Accessed November 7, 2016.

“The ‘metal’ categories: Bronze, Silver, Gold & Platinum,” Healthcare.gov. Accessed November 7, 2016.

“3 things to know before you pick a health insurance plan,” Healthcare.gov. Accessed November 7, 2016.

“If you don’t have health insurance: How much you’ll pay,” Healthcare.gov. Accessed November 7, 2016.

“Health insurance: How it protects you from health and financial risks,” Healthcare.gov. Accessed November 7, 2016.

“What Marketplace health insurance plans cover,” Healthcare.gov. Accessed November 7, 2016.

“Dates & deadlines for 2017 health insurance,” Healthcare.gov. Accessed November 7, 2016.

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