Under the Affordable Care Act (ACA), all health plans must now be assigned a metal level to help you and your employees easily understand how much the health plan will pay. Each metal level will have multiple options available, with different out-of-pocket costs (copays, deductibles, and out-of-pocket maximums) depending on the plan. Regardless of the plan you choose, all essential health benefits are covered.
Platinum Level Plans - You’ll pay a higher premium, but 90% of costs are covered by health insurance provider.
Gold Level Plans - 80% of costs are covered.
Silver Level Plans - 70% of costs are covered.
Bronze Level Plans - Your premiums will be lower, so the cost sharing is higher. 60% of costs are covered.
Ambulatory Patient Services - Includes doctor visits and specialty visits
Emergency Services - Includes emergency room, emergency transport and urgent care
Hospitalization - Includes hospital physician and facility services
Maternity and Newborn Care - Includes prenatal, delivery and post-natal care
Mental Health and Substance Use Disorder Services - Includes evaluation and treatment of mental health issues and services/treatments to treat alcohol/chemical dependencies
Prescription Drug - Includes prescription drug and enteral formulas
Rehabilitative and Habilitative Services - Includes services such as physical therapy, chiropractic care, inpatient services, hearing aids and prosthetic devices
Laboratory and Imaging Services - Includes X-ray and lab work, CT/PET and MRI scans
Preventive, Wellness and Chronic Disease Management - Includes coverage for routine physicals, screenings, checkups and immunizations, partial reimbursement for gym facility fees and treatment of chronic conditions
Pediatric Services - Includes pediatric vision benefits, such as vision exams and prescription lenses, and dental benefits, such as cleanings, exams and major dental care*
*SimplyBlue Plus plans are available with or without pediatric dental benefits. Pediatric dental is an Essential Health Benefit under the Affordable Care Act, which requires all insurers to include this coverage. Learn more about purchasing a medical plan from Excellus with the pediatric dental benefits included.
This is a fixed amount employees pay each time they use a medical service, such as a doctor’s office visit, prescription refill or a hospital stay. For example, a plan includes a $20 copay for a doctor office visit. Your employee goes to the doctor for strep throat, pays $20 at the time of the visit, and the insurance company pays the rest.
The insured individual's share of the costs of a covered health care service, calculated as a percent (for example, 20%). For example, a covered child’s eye glasses are $100. The plan covers 80%. So, your employee's coinsurance payment of 20% would be $20. The health insurance company would pay the rest, or $80.
Covered in full
100% of the total cost is covered by the health insurance company and your employee does not have to pay anything. All preventive services such as routine physicals, screenings, and vaccinations are covered in full.
The amount of money your employee has to pay before the health insurance company will make any payments towards health care services. The
deductible amount varies and is based on the type of plan. Employers can assist employees with their out-of-pocket expenses associated with a deductible plan by contributing to a Health Savings Account (HSA).
Health Reimbursement Arrangement (HRA)
An HRA is an employer funded, tax advantaged account that reimburses your employees for out-of-pocket medical expenses. The funds are not portable with the employee and the employer decides if unused funds may be carried over to the next year.
Health Savings Account (HSA)
An HSA is a tax-free account funded by the employer and/or the employee that helps them pay for qualified medical expenses such as lab fees, prescription drugs, contact lenses, chiropractor visits, and more. An HSA is owned by the employee and can roll over from year to year.
A specific amount that limits how much your employees have to pay out of their own pocket for health care services during a particular time period.
With SimplyBlue Plus, you’ll find the coverage that’s right for your business and your employees. Plans include no referrals, the largest provider network, zero cost preventive care (including routine physicals, screenings, and vaccinations), up to $600 for fitness facility memberships with ExerciseRewards, exclusive discounts with Blue365, online tools to help you manage your plan, and meet requirements of the Affordable Care Act with essential health benefits.
Plan Types & Cost Sharing
Member cost sharing varies by Metal Levels.
Copay plans PDF) that offer lower out-of-pocket costs for your employees
Hybrid plans (PDF) that have copays and coinsurance cost sharing to provide cost savings
Hybrid plans (PDF) that have copays and coinsurance cost sharing to provide cost savings. Some SimplyBlue Plus hybrid plans offer higher deductibles to keep premiums low, but have prescription coverage not subject to the deductible. These are great plans to offer the added incentive of a
Reduced-cost health insurance is available under the Healthy NY program to eligible small businesses and their employees.
Part of the Affordable Care Act is intended to improve dental coverage for children, including preventive, routine, and some major dental coverage. Enrollees who purchase medical coverage outside of the NY State of Health Marketplace are required to purchase a medical plan with pediatric dental coverage included or a qualified standalone plan. By purchasing a medical plan with dental included, you can be sure children will receive comprehensive coverage overseen by our staff of medical management experts and both medical and pediatric dental services will count towards your out of pocket maximums.
Our expert advisors can help you find plans to meet your company's needs: