Health Care Reform: What You Need to Know
U.S. businesses now have greater access to health insurance due to the Affordable Care Act, or ACA (the U.S. health care reform law).
Here are many ways the law may affect your group coverage:
- Guaranteed issue and renewal. With few exceptions, groups are guaranteed to have their coverage issued and renewed. Exceptions are if the group moves outside a service area, the group cannot pay premium costs, or the insurer withdraws from the market.
- Small group redefined. As of January 1, 2016, New York State defines "small group" as a business with 1 to 100 full-time equivalent (FTE) employees. This includes groups with 51 to 100 FTEs, which were previously considered "large groups." See our FAQs for what options this change brings, such as the chance to choose plans on the Marketplace.
- Shorter waiting period. Groups must allow employees to enroll in their group coverage no more than 90 days (including weekends and holidays) after becoming eligible for the coverage. This period reduces to 60 days if the group purchases Marketplace coverage.
- Fully covered preventive care. Group coverage must provide certain in-network preventive care services, like checkups, immunizations and certain screenings, at no cost-sharing (no deductible, copay or coinsurance). See which services qualify.
- Essential health benefits. Group coverage must include 10 categories of essential health benefits, like doctor visits, prescription coverage and lab services. This coverage may require cost-sharing.
- Out-of-pocket maximum. The ACA sets a limit on how much members pay toward their benefits each year. This applies only to in-network cost-sharing for essential health benefits. It doesn’t apply to premiums, out-of-network costs, non-covered services or non-essential health benefits, like adult dental and vision.
- Pre-existing conditions covered. The ACA guarantees coverage for qualifying individuals with a pre-existing condition, at the same premium cost as anyone else.
- Wellness incentives. Groups can encourage their employees to participate in wellness programs by offering to pay a portion of their premium contribution.
- Enrollment assistance. Groups can enroll independently or get help from brokers or navigators. Call 1-877-411-3625 to speak with someone at EmblemHealth who can assist you in enrolling for a Small Group plan.