New York Small Business
Health Insurance Plans 2023

The average price of a standard New York small business health insurance policy ranges from around $583 to over $1706 per employee per month based on; single or family, location, coverages offered, deductibles and more.

New York has implemented more health insurance regulations than most other states. If you are a small business owner, it is very important that you are aware of these regulations so that you can provide your employees with a policy that abides by the laws, yet also meets your needs - and the needs of your employees.

Of the many regulations that apply to small business insurance in New York, the most important regulations pertain to those that specifically impact New York small business health insurance plans.

Firstly, New York State government requires policies contain a provision known as the "guaranteed renewability" clause, which ensures that when an existing policy reaches its term, you are always granted the option to renew the policy for another term.

Another provision that it is important to be aware of pertains to pre-existing health conditions, or medical issues that were treated or diagnosed prior to the beginning date of the policy. According to New York State law, health insurance policies are only allowed to include pre-existing conditions exclusions for a period of up to 12 months, max.

Pre-existing medical conditions are those that were diagnosed or received medical treatment at least 6 months before the health insurance plan became effective. If you are changing your health insurance coverage in New York and there haven't been any breaks in your existing coverage, the pre-existing condition period from your old policy can be used to credit the condition on your new plan.

It's also important to note that in New York State, health insurance policies must be devoid of elimination riders. These riders permanently eliminate coverage for certain types of health conditions. Additionally, in New York State, there are health insurance policy provisions that relate to the insured's dependents.

If a parent's health insurance plan covers their dependents, it must also cover newborns and adopted children for a minimum of 30 days after their birth or adoption. Furthermore, dependents who are handicapped and over the legal age limit can still be covered by their parent's health insurance policy in New York.

According to NY State of Health website, to be eligible for the Small Business Marketplace (SHOP), your business or non-profit organization must:

• Have a physical business location in New York State
• Have between 1 and 100 FTE (Full-Time Equivalent) employees
• Offer, or intend to offer coverage to all full-time employees

In 2010, the Affordable Care Act (ACA or "ObamaCare") was passed by the United States Congress and was signed into law by Obama. Following its passage, provisions of the law have continued to be phased in, and as of January 1, 2014, the majority of American citizens and legal residents of the United States are required, by law, to have qualifying health care coverage.

If they fail to have coverage, they are responsible for paying an annual tax penalty for each month they aren't insured, which is known as the "individual mandate".

The cost of the penalty for failure to have qualifying coverage is $95 per adult and $47.50 per child, or 1% of your total taxable income; whichever amount is higher - as much as $285 per family. In 2017, the penalty increased, and has continued to increase thereafter.

Qualifying Exemptions For The Individual Mandate

Individuals who meet one of the following are exempt from the individual mandate and the associated tax penalties in NY:

• Illegal aliens
• Jailed individuals
• Religious objections
• The cost of health insurance coverage is higher than 8% of your household income
• Those who aren't covered for less than three months during the calendar year
• Those who have hardship waivers
• Your income level is blow the 100% poverty level

If you're a small business owner in New York, you must provide your employees with insurance. This is a requirement that was put into place by the Affordable Care Act.

Referred to as the Employer Shared Responsibility provision, all employers must offer their employees at least one of the ACA-compliant New York small business health insurance plans, otherwise then can face fines of up to $2,000 per employee.

New York small business owners can purchase coverage for their employees through the state's Small Health Option Program (SHOP) exchange, or from a private insurance agent or broker.

Affordable Care Act Standardized Essential Health Benefits

As per the ACA, all qualifying health insurance plans must offer 10 standardized essential benefits.

Depending on the state, additional benefits may also be required. The 10 ACA standardized essential benefits are as follows:

1. Ambulatory patient services (medical care that is offered without being admitted to a hospital)
2. Emergency services
3. Hospitalizations, such as overnight stays and surgical procedures
4. Lab services
5. Mental health and substance abuse disorder services, including behavioral health treatments, such as psychotherapy and counseling
6. Pediatric health care services, including vision and oral care; however, adult vision and dental coverage aren't essential health benefits under ACA
7. Pregnancy, maternity, and newborn care, including before and after birth
8. Prescription pharmaceuticals
9. Preventative and wellness services, as well as management for chronic diseases
10. Rehabilitative and habilitative services and devices, including services and devices for injuries, disabilities, and chronic health conditions

Additional Health Benefits Mandated In New York

In addition to the above-mentioned ACA essential health benefits, policies that are issued in New York must include the following health benefits:

• Blood products and services
• Breast reconstruction surgery
• Chiropractic care
• Diabetes care management, including supplies, equipment, and then self-management education
• Dialysis
• Durable medical equipment
• Emergency transport serves
• Home health care services for individual and group insurance
• Infertility treatments
• In-patient end of life care
• Post-mastectomy reconstruction
• Private pharmaceuticals
• Post-mastectomy reconstruction
• Private duty nursing
• Rehabilitative inpatient physical therapy
• Second medical opinion for cancer
• Skilled nursing facility care

Standardized New York Small Business Health Insurance Plans

In order to make it easier to compare costs and benefits, the Affordable Care Act has designated all qualifying New York small business health insurance plans to be one of four metal colors, including Bronze, Silver, Gold, and Platinum.

Each of these designations is based on the average amount of health care costs that the plan will cover, which is illustrates at percentages of how much the insurance company will cover for health care, as well as the amount the insured will have to pay out-of-pocket.

All insurance companies that are participating in the federal or state health care exchange program must offer at least the Silver and Gold New York small business health insurance plans.

All four of the metal plans have a shared maximum out-of-pocked amount that the insured can be charged during any calendar year. The following table illustrates this information:

Guaranteed Issue

As per the ACA, individuals cannot be denied coverage or charged higher premiums because of their past health history, or their gender.

Additionally, look-back and waiting periods cannot be imposed. Additionally, policies are effective when they are issued and all coverage is renewable if the individual chooses to renew the policy.

However, plans can be canceled if the individual fails to pay their premiums or commits fraud.

A premium is the amount the insured must pay out-of-pocket in order to maintain their health insurance policy. The premiums that are charged for any of the qualifying metal plans can be based on the following:

• Age of the individual
• Whether or not the individual uses tobacco
• Where the individual lives, based on a rating area
• The number of family members who will be enrolling

While there are several types of health insurance plans to choose from, the following plans are the most popular among NY small business owners:

Health Maintenance Organization - Simply known as an "HMO", this type of plan offers a variety of health-related services via a network of health care providers and hospitals that exclusively contract with the HMO, or who agree to offer their services to members of the HMO. Employees who participate in this type of plan usually have to choose a primary care physician (PCP), and receive most of their care from this physician. If a specialist is needed, the PCP will recommend one that is affiliated with the HMO.

Preferred Provider Organization - More commonly referred to simply as "PPO", this type of health insurance plan is the most common among New York small business owners. The insurance company provides a preferred list of health care providers, and employees must receive their medical care from the doctors and hospitals on that list for their claims to be paid at the highest level possible - but they also have the flexibility to see any other provider anywhere in or out of state.

Point-of-Service Plan - Known as a (POS), this type of health insurance plan provides access to health care services at a lower overall cost, but with fewer choices. Members can access care from in-network or out-of-network providers and facilities, but coverage is better when you stay in-network. POS plans may vary, but generally, plans are considered a blend of HMO and PPO plans - offering more flexibility than HMOs, but less than PPOs.

Health Savings Account - A health savings account (HSA) is a special type of bank account that allows participants in the insurance plan to save money that can be used specifically for the medical care they require in the future. HSA-qualified health insurance plans are usually PPO plans that are specifically designed to be used with an HSA.

Indemnity Health Insurance - This type of health insurance plan allows members to control their own health care and to visit any doctor or hospital they choose. The insurance company would then pay a pre-determined percentage of the total charges for the services that were rendered. Employees may have to pay for some types of services up-front and then they can submit a request for reimbursement with the insurance company.