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Prepare for new health insurance rules

A looming government shutdown might alter the way the federal government does business in coming weeks, but late this week it looked unlikely to change when new parts of the Affordable Care Act come into play.

On Tuesday, the new health insurance exchange application process will begin. Those in the health care industry strongly recommend we all start paying closer attention to insurance options and how they will impact our medical care – and pocketbooks.

The goal of the new health care is to insure more Americans in a more affordable way. Those who pay enough attention, and compare plans, might end up with better insurance at a savings. Those who don’t could end up penalized for their lack of interest because they will pay a penalty – the U.S. Supreme Court has deemed it a “tax” – local health insurance companies warn.

“You should at least do as much research when buying health insurance as you would when buying a major appliance or new car,” says Art Wingerter, president of Univera Healthcare, which serves 145,000 members in Western New York. The uninsured and those seeking less expensive health care have until March 31 to enroll for new insurance through New York State of Health, the state’s new online health insurance marketplace, or exchange. Coverage can start as soon as Jan. 1.

Here are tips for individuals from Univera, among the regional health insurers which will offer plans on the state exchange.

• Start the process online at Those seeking individual, family and small businesses coverage “will be able to use the Marketplace to help them compare insurance options, calculate costs and select coverage online, in-person, over the phone or by mail,” according to the state website. “The Marketplace will help people to check their eligibility for health care programs like Medicaid and sign up for these programs if they are eligible. The Marketplace will also be able to tell what type of financial assistance is available to applicants to help them afford health insurance purchased through the Marketplace.”

• To see if you’re eligible for financial help, use the Tax Credit and Premium Estimator at Your premium may be reduced if your household income is below 400 percent of the federal poverty level, which is $45,960 for individuals or $94,200 for a family of four.

• Determine your health care needs. List your typical health services and costs in a given year. Use the list to help you pick a plan that best fits your situation. For example, if you go to the doctor often, you may want a plan with lower co-pays for doctor visits.

• Consider all costs. Don’t just shop for coverage based on a health plan’s premiums. Consider other costs, such as deductibles and co-pays.

• See which health plans work with your doctor. It can be costly to see a doctor, pharmacy or hospital that’s not in a health plan’s network. You may need to double check this information with the provider or health insurer.

“It won’t do you a lot of good to purchase less expensive coverage, if the insurer’s provider network doesn’t include your doctors, or your preferred hospital,” Wingerter said.

Here are some questions and answers provided by Independent Health when it comes to individual responsibilities in the Affordable Care Act:

What are my choices for buying coverage which will go into effect next year?

• Purchase coverage through the state exchange, which will be the only way to receive a federal premium subsidy or cost sharing (if eligible based on income.)

• Buy directly from an insurer, as is done today.

• Go without insurance coverage and pay a penalty.

Are individuals required to buy health insurance?

Yes, for those who do not have health insurance beginning Jan. 1. This penalty – or tax – is assessed annually on every member of a household who does not have coverage.

• The penalty for 2014 is $95 for adults or 1 percent of income – whichever is higher – and $47.50 for dependents under 18.

• In 2015, the penalty is 2 percent of income, or $325 per person.

• By 2016, the penalty increases to $695 for adults or 2.5 percent of income (whichever is higher), and $347.50 for dependents under 18.

• The penalty is capped at the amount of the lowest cost bronze product available in the exchange. For an individual in Buffalo, that’s $221 for next year; for a family of four, it’s $630.

Can family members choose different coverage on the exchange?

Yes. Family members can select different options to find the most affordable coverage for their family. For example, a single parent with two children may find it more affordable to enroll in a single policy for their own needs and then enroll their two children in Child Health Plus coverage.

Are there any exemptions from the individual coverage requirement?

Yes, those with a religious conscience exemption, who cannot find coverage with a premium less than 8 percent of their income (although these people may be able to buy a catastrophic coverage plan), and several specialized groups – including undocumented immigrants, those in prison and Native Americans – won’t have to pay an individual penalty.

Am I allowed to buy insurance on the exchange if I have employer coverage but prefer the exchange?

An individual who has an offer of coverage from an employer which meets the standards for affordability and minimum value is not able to receive a premium subsidy in the exchange, though he or she would still be able to purchase coverage at full cost.

Read more about the exchange in the coming days in The Buffalo News and at, and next week in WNY Refresh.