Employer Sponsored Health Coverage

The majority of non-elderly Americans get their health coverage through employer sponsored plans, but the ways those plans provide financial protection is changing. According to a new survey by the Kaiser Family Foundation, employers are increasingly relying on cost-shifting through high-deductible plans, higher premiums, and plans with larger co-pays. That means workers and their families have more to lose when healthcare costs spike.


Tools such as price transparency calculators and employee wellness programs are growing in popularity as consumers are pushed to treat healthcare purchasing decisions more like other household expenses. It may pay to shop around and avoid unnecessary office visits or procedures, but healthcare costs are not like other household purchases. Price tags don’t always communicate value, and high quality care is not one-size-fits-all. For some consumers paying more to get the care that suits their needs is the only viable option. The rise of narrow networks, which offer few choices of providers and hospitals in an effort to curb costs to insurers, exacerbates the problems these consumers face.


With wages increasing slowly, consumer advocates are on the alert for healthcare costs that prevent workers from seeking necessary, high-quality care. Nobody should forgo a trip to the doctor when they’re ill because they can’t meet their deductible or afford the copay. The American narrative of employer sponsor health insurance only works if employees aren’t impoverished the moment they need services.

By Andrew Leonard, Sr. Policy Associate for Health, Housing and Income Security, Children’s Defense Fund – NY


Starting this November, many low- and moderate-income New Yorkers will be able to enroll in a new comprehensive and affordable health insurance product, known as the Essential Plan. Without a doubt, the New York State of Health Marketplace has been a huge success in New York State, enrolling over 2 million people in coverage, many for the first time! Yet, despite these significant gains, some New Yorkers find themselves without insurance or struggling to afford the private insurance have, even with financial assistance from the Marketplace. Many of these individuals will be newly eligible for the Essential Plan.

o-BEST-HEALTHCARE-facebookLike Qualified Health Plans, the Essential Plan will cover all of the ten Essential Health Benefits, including emergency services, inpatient hospitalization, primary care, urgent care, sick visits, lab work, radiology, reproductive health care and more.

Those who qualify for the Essential Plan will pay a premium of either $0 or $20, depending on their income. There will be no deductible, but some consumers may be required to pay a small co-pay for services like doctor visits, hospital stays, and prescription drugs.

The Essential Plan will be available to US citizens earning more than the Medicaid eligibility threshold, but less than 200% of the Federal Poverty Level (FPL) (e.g. a single person earning more than $16,242 but less than $23,540). Lawfully-present immigrants, such as green card holders and those seeking refugee status, will be eligible for Essential Plan coverage as long as they earn less than 200% of the FPL. That means that most lawfully-present immigrants below the Medicaid income threshold, currently eligible for state-funded Medicaid, will be transitioned to Essential Plan coverage.

Enrollment in the Essential Plan begins November 1, 2015 for coverage beginning January 1, 2016. From then on, eligible individuals will be able to enroll all year long, not just during the Marketplace’s Open Enrollment period. It’s an exciting time in New York State!

To enroll or learn more about the Essential Plan, contact the NY State of Health at (855)-355-5777 or www.nystateofhealth.ny.gov.

You can also get free one-on-one help from a Navigator or Certified Application Counselor, certified by NY State of Health, who serves your area: http://info.nystateofhealth.ny.gov/IPANavigatorMap. Or contact Community Health Advocates: (888)-614-5400 or http://www.communityhealthadvocates.org/.

The ACA makes insurance more affordable for people through a cost-sharing reduction (CSR) benefit. CSRs are available to consumers with incomes between 138% and 250% of the Federal Poverty Line ($27,311 to $49,475, for a family of three) who purchase Silver level plans. CSRs are sliding scale discounts on cost sharing, including deductibles, co-pays, and co-insurance. New analysis from Washington D.C.-based Avalere Health of nationwide Marketplace enrollment for 2015 shows that only 73% of enrollees eligible for cost-sharing reductions chose Silver level plans. Thus 2.2 million consumers forfeited this benefit.

According to Avalere’s analysis, “consumers may not be aware that CSRs are available and the benefits they offer. ‘Additional consumer education and more sophisticated decision support tools are likely needed to ensure that all patients are accessing the benefits available under the Affordable Care Act,’ said Elizabeth Carpenter, vice president at Avalere. ‘Specifically, consumers need tools that highlight the tradeoff between monthly premiums and out-of-pocket costs and demonstrate the benefits of cost-sharing reductions.’”

In New York, however, 78% of eligible enrollees chose plans that came with CSRs – 5% better than the national average. New York also saw a steep curve between the three CSR tiers: 97% of those eligible for the highest level of CSR subsidy – 94% actuarial value – enrolled in Silver plans; but only 62% of people eligible for the lowest level of CSR subsidy – 73% actuarial value – enrolled in Silver plans (see graph below). This suggests that New York consumers are making strategic enrollment decisions. New York’s 11,000 assistors, who disproportionately serve consumers with lower incomes, are likely a part of our success story.

CSR levels graph 2New York’s data also suggest that consumers eligible for the lowest level CSRs (CSR-III) – with a $1200 deductible – may still face affordability problems. These consumers may be choosing Bronze level plans to save money on premiums, or they may forgo CSRs altogether and “buy up” to Gold level plans.

Come 2016, consumers in the CSR-I and CSR-II bands will qualify for the Essential Plan (EP), which will have very low cost or no cost premiums and minimal cost sharing. This may underscore the affordability issues facing consumers eligible for the CSR-III subsidies, earning between $39,581 and $49,475, for a family of three.


By Heidi Siegfried, Esq., Project Director of New Yorkers for Accessible Health Coverage and Health Policy Director for Center for Independence of the Disabled, NY


In its second Open Enrollment report, the New York State of Health Marketplace (NYSOH) identified trends in plan selection. One stand-out trend is the high uptake of out-of-network products in the areas in which they are offered.

An “out-of-network” product provides insurance coverage for services delivered by providers that do not belong to the carrier’s network. During the 2015 Open Enrollment period, carriers offered Qualified Health Plans (QHPs) through NYSOH with out-of-network coverage in 11 counties of the state: Albany, Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Rensselaer, Saratoga, and Wyoming counties.

In these 11 counties, a whopping 21 percent of QHP enrollees selected plans with an out-of-network benefit. QHPs with an out-of-network benefit are more expensive than plans that only cover in-network providers – costing 7% to 40% more in monthly premiums – but a significant share of consumers clearly value this option when it is offered.

HCFANY will continue to advocate that carriers should offer out-of-network options in all counties. New York is one of only three states where out-of-network coverage is not widely available in the individual market. As insurers have moved to narrower networks and more limited networks, it has been especially hard for people with serious illnesses and disabilities who are receiving care from many providers to find a network that includes all of their providers. Even with improved network adequacy and external review appeal processes, many consumers would prefer to purchase a more expensive plan with out-of-network coverage than a cheaper plan that requires them to say in-network. People paying for vital treatments with trusted providers – HIV and cancer specialists, for example – should retain the right to see these providers without having to pay out-of-network rates and cover the cost entirely out-of-pocket.



NYS counties

Eleven New York counties (shown in green) offer out-of-network plans in the Marketplace


This is the fifth in a series of blog posts about the NYSOH 2015 Open Enrollment Report.