Health Care Reform: What You Need to Know | EmblemHealth

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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:

  1. 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.

  2. 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 below for what options this change brings, such as the chance to choose plans on the Marketplace.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. Pre-existing conditions covered. The ACA guarantees coverage for qualifying individuals with a pre-existing condition, at the same premium cost as anyone else. 

  8. Wellness incentives. Groups can encourage their employees to participate in wellness programs by offering to pay a portion of their premium contribution.

  9. Enrollment assistance. Groups can enroll independently or get help from brokers or navigators. Call 866-274-0060 to speak with someone at EmblemHealth who can assist you in enrolling for a Small Group plan.

Frequently Asked Questions

Is my small group certain to get coverage? Will we be able to renew it?
In most cases, all health insurers offering coverage in a state's small group market must accept every group that applies for new or renewed coverage.

In what cases might a small group be turned down for coverage?
This would only happen in rare cases, such as if the group moves outside a service area, the group cannot pay premiums, or the insurer withdraws from the market.

How is small group defined by New York State?
As of 2016, "small group" was redefined to mean a group with 51 to 100 full-time equivalent (FTE) employees. Groups with 101+ FTEs are now considered large groups.

What general changes can I expect now that my business of 70+ full-time equivalent employees switched from a large group to a small group?
Here are a few ways your group will be affected:

  • Community rating: All employees in your group will now pay the same premium, regardless of their age, sex, health status or occupation.
  • Still subject to the employer mandate: Under this ACA policy, your group will still be required to offer adequate, affordable health insurance to all your full-time equivalent employees and those employees' dependents.


What changes can I expect now that, due to my group size, I'm switching from an EmblemHealth large group plan to an EmblemHealth small group plan?
Here are some of the major changes you can expect:

  • Access to the Prime network: All EmblemHealth small group plans use the Prime network. This network includes thousands of experienced, community-based primary care and specialty doctors in both private and group practices. It services 28 New York counties, including the five NYC boroughs, Westchester, Long Island and regions stretching north of Albany.
  • HMO products: All EmblemHealth small group plans are HMO plans. This means your employees must see doctors in the Prime network for their care to be covered and they must get referrals from a Prime primary care physician to see specialty doctors.
  • No out-of-network coverage: EmblemHealth does not offer small group plans with out-of-network coverage. So, your employees will need to see doctors in the Prime network for their care to be covered.

I'm ready to apply? What's next?
First, it's important to know if you're eligible for tax credits so you get the best deal. Call us at 1-877-347-0440 to check your eligibility, estimate costs and start enrolling.

When can I enroll in small group coverage, both on and off the NY State of Health Marketplace?
You can apply any month of the year.

Can we get help enrolling in small group coverage?
Yes! Here are a few ways to get the help you're seeking:

  • From a broker or navigator: From the Marketplace website, choose EmblemHealth from the "Issuer Affiliations" drop-down menu to work with someone familiar with our plans.
  • From EmblemHealth: Call us at 1-877-347-0440 for help choosing the right plan.
  • From the Marketplace: Call 1-855-355-5777 or call 711 if you use a TDD/TTY due to a hearing or speech impairment.

What types of small group health plans does EmblemHealth offer?
Off the NY State of Health Marketplace, we offer plans in 28 counties throughout New York State. Here's a look at the types of small group plans we offer:

  • Both Standard and Nonstandard plans: Standard plans are those whose benefits and out-of-pocket costs are defined by New York State and are the same across insurers offering these plans in the State. Nonstandard plans are those whose benefits and out-of-pocket costs are defined by the health insurer offering the plans and are unique to that insurer.
  • Off the Marketplace: We offer two standard metal plan (EmblemHealth Bronze HSA and EmblemHealth HMO 15/35 [Platinum]) and four nonstandard metal plans (Emblemhealth Silver Value, EmblemHealth Bronze Value and EmblemHealth HMO 40/60 [Gold] and EmblemHealth Gold Open Access). The EmblemHealth Silver Value and Bronze Value plans and Gold open Access plan include dental and vision coverage for adults. All small group plans include dental and vision coverage for kids.


  • Do you have employees who visit the doctor often? You may want to offer a choice of plans that cost more per month (like Platinum or Gold), but have lower cost-sharing.
  • Do your employees see the doctor only rarely? You might offer a choice of plans that cost less per month (like Silver or Bronze), but have higher cost-sharing.

Which doctors are in EmblemHealth's medical network?
EmblemHealth's small group medical plans use our Prime network, a tailored network of experienced primary care physicians and specialists plus facilities and leading hospitals throughout 28 New York counties, including the five NYC boroughs, Westchester, Long Island and regions stretching north of Albany.

The Prime network includes AdvantageCare Physicians, a multispecialty physician group practice focused on personalized, team-based care, with locations throughout New York City and Long Island. Learn more.

What costs will my employees need to pay for their health insurance?
There are two main costs: premium and cost-sharing. The actual dollar amounts they'll pay depend on the plan they choose, how much the employer contributes to their premium, and whether they get care from in-network providers.

What's a premium?
It's the periodic cost of a health plan. Premiums are paid on a regular schedule (for example, each month) whether or not your employees use their benefits. Generally, employers and employees share the premium costs; the rules depend on the type of coverage the employer chooses.

What out-of-pocket costs can my employees expect to pay for their health care?
Your plan may include cost-sharing, which is the share of the costs your employees pay to use their benefits. There are three main forms, which may or may not apply depending on the plan they choose:

  • Deductible: The amount an insured person may need to pay each calendar year before the health insurer starts paying for covered health services. Some benefits, like certain preventive care services, aren't subject to the deductible. This means your employees won't need to pay into their deductible before using those benefits.
  • Copay: A fixed amount an insured person may need to pay when seeing a doctor or picking up prescription medication, usually after meeting the deductible, if one applies.
  • Coinsurance: The percentage of the allowed cost of services your employees may need to pay toward a covered health service, usually after meeting the deductible, if one applies. (The allowed amount is the cost we and our network providers have agreed to.) Here's how coinsurance works: Let's say a doctor charges your employee $100 for a service, and we've agreed to pay the doctor $50. If the employee owes 50% of the allowed amount of $50, then the employee would pay $25 for the service.