Health Care

Q: Under the Affordable Care Act, can an employee buy individual health coverage through the state exchange if his employer offers him coverage? Does it matter how many employees the employer has?

A: Almost anyone may purchase coverage through the individual exchange, whether or not they can get coverage through work. The only people who cannot are those who are: 1. Residing in the U.S. in violation of its laws, or 2. incarcerated. Anyone else is free to buy (or not buy) through the exchange. However, if the employer’s plan covers at least 60 percent of the insurer’s allowed charges, and if the employee contribution for self-only coverage is less than 9.5 percent of that employee’s gross household income, the employee will not qualify for a premium tax credit. That’s a pretty strong incentive for employees to go with the employer’s plan. 

Employer size does not affect an employee’s ability to buy coverage through the exchange. However, employers with more than 50 full-time equivalent employees face a tax penalty if one or more full-time employees get premium tax credits by purchasing coverage through the exchange. Employers with fewer than 50 full-time equivalents do not have to worry about that.

Are you planning to sell, solicit, or negotiate accident and health insurance through the NY State of Health exchange starting October 1^st? All producers accessing the Small Business Health Options Program or SHOP will need to complete mandatory certification training before placing their business in the program. 

Health insurance can be sold, including through the NY State of Health Exchange effective October 1, 2013, under the following licenses:

LA – Life, Accident & Health, Variable Life, Variable Annuities Agent
Insurance Law 2103(a)

LB – Life Broker
Insurance Law 2104(b)(1)(a)

BR – Property & Casualty Broker (all lines except life, bail bonds, annuities)
Insurance Law 2104

Note

A PC licensee (Property & Casualty Agent) MAY NOT sell health insurance.
Insurance Law 2103(b)​