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Changes for Individuals & Families

The Affordable Care Act (ACA), passed by Congress in March 2010, expands the availability of coverage for individuals. The law expands coverage, provides consumer protections and creates marketplaces (exchanges) to assist individuals and families with comparing plans and purchasing insurance coverage.

Some of the benefits of the ACA are already in effect. Individuals and families will have the opportunity to enroll in plans beginning in October 2013, with coverage effective in 2014.

Excellus BlueCross BlueShield will be your trusted guide on the path to understanding how health care reform affects you.

For definitions of terms found below and for additional tools and resources, please refer to the 'Resources' section.

Health Care Reform Impacts to Individuals & Families

A provision of the ACA known as the individual mandate will require U.S. citizens and legal residents to have health insurance in 2014. Those without coverage will pay a tax penalty based on household income.

To make coverage more affordable, a premium tax credit (PTC) will be available to assist eligible individuals who cannot afford to purchase coverage.

The tax penalty will be either a flat fee or a percentage of household income, whichever is greater. It will be begin in 2014 and increase over time. The flat dollar tax penalty will be charged for each person in a household, up to 3 members (including dependents).

Tax penalty amount per person 2014 2015 2016 2017
Flat amount
- or -
$95 $325 $695 $695 + adjustment for inflation
Percentage of taxpayer’s household income 1% 2% 2.5% 2.5%

Exemptions from the tax may include: Some religious exemptions, members of health care sharing ministries, unauthorized aliens, incarcerated individuals, U.S. citizens living abroad, taxpayers below the income tax filing threshold, members of Native American tribes and individuals granted hardship exceptions.

Premium Tax Credit (PTC)

A PTC is a tax credit that an individual can receive when purchasing coverage to help offset the cost of that coverage. A taxpayer who meets the following criteria may be eligible for a PTC:

Anyone can purchase coverage through an Exchange, however only those meeting the above criteria may be eligible for a tax credit.

What are health insurance exchanges?

Who is eligible to purchase through an exchange?

An individual must:

Laws that Affect Employer-Provided Coverage

If you are currently insured by your employer, there are changes to coverage already in effect. Some of the key changes that may affect your employer-provided coverage are listed in the 'Businesses' section.

If you need coverage today, you may be eligible to enroll in one of our current plans:

 

* Please note that this plan will only be available until December 31, 2013.  We know how important it is for our members to have uninterrupted health insurance coverage.  If you decide to enroll in this plan before the end of the year, we will automatically re-enroll you in a health plan that most closely matches your benefits and that meets all of the Health Care Reform guidelines for 2014.  You always have the option to change to another plan that works better for you beginning anytime after October 1, 2013 when new plan information is available.  Medicaid, Family Health Plus and Child Health Plus plans will not be affected by these changes.  

FOR MORE INFORMATION
If you are a current member,  please call the number on the back of your membership card.  
Please call Customer Service at 1-800-499.1275.  For TDD/TYY call 1-800-421-1220.

As the world of health care changes, we are committed to helping you keep up with life’s changes.

To comply with health care reform mandates, we will be retiring some of the products currently available to our individual members (who purchase insurance directly from us). All members of these plans must transition into a new, compliant product by January 1, 2014. We will be recommending a new plan that most closely matches the benefits or cost of your retiring plan.

Don't worry — there will be new health insurance options beginning in October 2013 and you may be eligible for cost-saving tax credits that will help you pay for them. We are here to help you understand your choices and guide you to the best plan.

Sample of Product Discontinuance Group Member Letter (PDF)

Sample of Product Discontinuance HNY Individual and Sole Proprietor Letter (PDF)

What happens next

Individual / Direct Pay: Members will be transitioned to a new health care reform compliant plan called ExchangeBlue as of January 1, 2014. Sign up for email updates to stay informed as more information is available.

Sole Proprietors: Members have the option of renewing into a health care reform compliant plan called ExchangeBlue on January 1, 2014 or they can choose to transition on their plan’s current effective date. Sign up for email updates to stay informed as more information is available.

If you are interested in a plan other than what is recommended, we will have additional options to choose from beginning October 1st.

Retiring Product Replacement Product Comparison Chart
ValuMed &
ValuMed Plus
ExchangeBlue See details below. Compare ValuMed & ValuMed Plus to ExchangeBlue (PDF)
Direct Pay HMO &
Direct Pay POS
ExchangeBlue See details below. Compare Direct Pay HMO & Direct Pay POS to ExchangeBlue (PDF)
Direct Pay BlueCross BlueShield Indemnity Options ExchangeBlue See details below. Compare Direct Pay BlueCross BlueShield Indemnity Options to ExchangeBlue (PDF)
Healthy NY Individual &
Sole Proprietor Options
ExchangeBlue See details below. Compare Healthy NY Individual & Sole Proprietor Options to ExchangeBlue (PDF)

ExchangeBlue Details

Plan types include Copay, Copay/Deductible and High Deductible Health Plans. Plus, all options include:

Other great perks you will get with ExchangeBlue include:

Topic Brief Description Tools & Resources
Annual Limits
see also Lifetime Limits
Law prohibits imposing annual limits on Essential Health Benefits and any lifetime dollar limits.

No lifetime limits, restricted annual limits overview (PDF)

List of essential benefits (PDF)

Claims and Appeals According to the Patient Protection and Affordable Care Act of 2010, the rules for internal claims, initial requests for services, appeals and external review processes for group health plans and insurance coverage will change.

Appeals Summary and Q&A (PDF)

Appeals Requirements for Self Funded Groups (PDF)

Dependent Coverage to Age 26 By allowing children to stay on their parents plan, the Patient Protection and Affordable Care Act (PPACA) makes it easier and more affordable for young adults to get health insurance coverage.

Dependent coverage overview (PDF)

Sample letter explaining a special enrollment period for dependents to age 26 (PDF)

Early Retiree Reinsurance Program The Patient Protection and Affordable Care Act established the Early Retiree Reinsurance Program (ERRP) to provide continued health insurance coverage to retirees age 55 years and older, plus their dependents, who are not eligible for Medicare. As of May 5, 2011 the existing ERRP is closed by the authority of the HHS Secretary.

Visit errp.gov

Early Retiree Fact Sheet (PDF)

Employer Checklists The following checklists are meant as a general guideline for Health Care Reform actions that may be required of employer groups or Excellus BlueCross BlueShield. For more information, please contact your Sales Consultant.

Fully-Insured Checklist (PDF)

Self-Funded Checklist (PDF)

Essential health benefits Non-grandfathered plans in the individual and small group markets both inside and outside of the Exchanges must cover essential health benefits (EHB) beginning in 2014. EHB include items and services within the following 10 benefit categories: (1) ambulatory patient services, (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, and (10) pediatric services, including oral and vision care. Each state will define the EHB benchmark plan for 2014 and 2015. HHS intends to evaluate the benchmark process for 2016 and beyond based on evaluation and feedback.

Sample letter explaining essential health benefits (PDF)

List of essential health benefits PDF)

Exchanges Exchanges allow individuals and small employers to select from competing plans through either a state-based American Health Exchanges for individuals or a Small Business Health Options Program (SHOP) for qualified small employers. Governor Cuomo's press release and the Executive Order to establish the New York Health Benefit Exchange.
FSA Contribution Limit For plan years beginning on or after January 1, 2013, the maximum allowable salary reduction contribution to a cafeteria plan (Section 125 plan) Health Flexible Spending Account will be $2,500. FSA Contribution Limit FAQ (PDF)
Grandfathering "Grandfathering" allowed some plans to be exempt from some Health Care Reform provisions.

Grandfathering Advantages and Disadvantages(PDF)

Grandfathered Plans - List of Requirements (PDF)

Grandfather Status Application for Fully-Insured Groups (PDF)

Grandfather Status Recertification Form for Fully-Insured Groups (PDF)

Certification Form for Grandfather Status for Self-Insured Groups (PDF)

Lifetime Limits
see also Annual Limits
Law prohibits imposing annual limits on Essential Health Benefits and any lifetime dollar limits.

No lifetime limits, restricted annual limits overview (PDF)

List of essential health benefits (PDF)

Medical Loss Ratio (MLR) Reporting A Medical Loss Ratio or MLR is the percentage of premium dollars insurers spend to provide covered medical services and improve the quality of health care for their members.

Employer MLR Notification Letter (PDF)

Member MLR Notification Letter (PDF)

Read more details in our press release

Frequently Asked Questions (FAQ) (PDF)

No pre-existing for children under 19
see also Pre-Existing Conditions
As of September 2010 there are no pre-existing exclusions for children under age 19. Beginning in 2014, this provision applies to everyone, including adults.

No pre-existing condition exclusions overview (PDF)

Patient-centered Outcomes Research Fee The Patient-Centered Outcomes Research Tax, also known as the Comparative Effectiveness Research Fee, is a fee paid to the government to fund Patient-Centered Outcomes Research Institute (PCORI) research. Frequently Asked Questions (PDF)
Pre-Existing Conditions Exclusions As of September 2010 there are no pre-existing exclusions for children under age 19. Beginning in 2014, this provision applies to everyone, including adults. N/A
Premium Rate Reviews Establish a regulatory process for federal and state governments to review increases in medical plan premiums. N/A
Premium Reporting Require health plans to report the proportion of premium dollars spent on clinical services, quality, and other costs. Managing to medical loss ratios of 85% for plans in the large group market and 80% for plans in the individual and small group markets. (Requirement to report medical loss ratio effective plan year 2010.) N/A
Preventive Services
see also Women's Preventive Services
The Patient Protection and Affordable Care Act of 2010 (PPACA) requires health plans to cover designated preventive services without any member cost sharing.

Preventive services overview (PDF)

List of preventive services (PDF)

Rescissions Limitations on the way an insurer terminates coverage/service to a customer

Rescissions for Group Health Plans (PDF)

Retiree only certification Employers should complete this form if they think that one or more of their plan options qualifies for an exemption from the market reform provisions of the Patient Protection and Affordable Care Act because the plan(s) provides coverage for fewer than two active employees, often known as a retiree only plan. Certification form (PDF)
Small Business Health Options Program (SHOP) The Small Business Health Options Program (SHOP) is intended to create a marketplace for small employers to purchase health insurance for their employees. N/A
Small business tax credits In an effort to help small employers offer affordable coverage to their employees, the Patient Protection and Affordable Care Act provides for tax credits for qualified small employers.The credits increase in 2014, but are only available for coverage purchased on an Exchange.

How to Get Small Business Tax Credits

Fact sheet (PDF)

Summary of Benefits Coverage The Departments of Health and Human Services, Labor and Treasury recently issued final regulations requiring health plans to provide a SBC and Uniform Glossary that clearly explain benefits and coverage within a standardized template with uniform language. Learn more or request a Summary of Benefits and Coverage (SBC)
Temporary High-Risk Pool
aka Pre-existing Insurance Plan (PCIP)
A temporary program called the Pre-Existing Condition Insurance Program (PCIP) that makes coverage available for individuals who have a pre-existing medical condition. PCIP programs will operate until January 2014. At that time other provisions of the ACA will go into effect for individuals to purchase coverage.

Learn more about how the Pre-Existing Condition Insurance Plan (PCIP) works in your state

W-2 reporting PPACA contains a requirement for employers to report the cost of health coverage under an employer sponsored group health plan on an employees W-2 form. The cost includes both the cost paid by the employer and contributions from the employee.

W-2 Fact Sheet for employers (PDF)

Women's Preventive Services
see also Preventive Services
The Patient Protection and Affordable Care Act (PPACA) requires health plans to cover designated womens preventive services without cost sharing for the member. Cost-sharing includes deductibles, copayments and coinsurance. Some of the benefits and services outlined in the womens preventive guidelines are already included within the existing PPACA preventive services requirements.

Women's Preventive Services FAQ (PDF)

List of Women's Preventive Services (PDF)

Safe Harbor Eligible Employers Form (PDF)

Exempt Religious Employers Form (PDF)

The information provided here is not intended to advise you on how to comply with any provisions of the referenced legislation or related legislation or regulations, nor is it otherwise intended to impart any legal advice.

Need Help?

Our dedicated insurance advisors can help you get coverage:

For HMOBlue Option, Blue Choice Option or Child Health Plus, call 1-800-716-4885
Hours

Mon. - Thurs. 8 a.m. to 6 p.m.
Friday 9 a.m. to 6 p.m.

For All Other Plans, call
1-888-679-7105

TDD/TTY: 1-800-421-1220
Hours

Mon. - Thurs. 8 a.m. to 7 p.m
Friday 9 a.m. to 7 p.m.

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