How to navigate the New York State Health Insurance Exchange? (the ACA)
August 17, 2014 9:25 AM   Subscribe

I am in Manhattan, New York City, and I have to change my health insurance. Can you help me with the Exchange thing?

I'm being told that, after many years with Oxford Health, via a two-person (two spouses) S-Corp through which my husband, son, and I paid the premiums, that this sort of spousal corp. is not allowed anymore via the Affordable Care Act and I will be dropped on September 30th. My husband had been opting out recently anyway because he is on Medicare now. So it's me and my 21-year-old son. I will only be using the new A.C.A. plan for one year, because after that I'll be on Medicare, and we'll just be using the A.C.A. plan for my son.

Complication: I'm having hip replacement surgery on Sept 5th, and, while my surgery will be covered by Oxford, when I go for follow-up appointment with the surgeon I will have to use my new insurance, so I have to pick a plan that my surgeon takes.

He only takes three plans on the Exchange, I'm told: Affinity Gold Preference, which I see clearly on the Exchange website, some form of Emblem (HIP), more about which the surgeon's secretary did not specify and which I cannot find on the exchange, and something called United Health Care Compass, which I can't find on the exchange.

First question: Since I can't find United Compass, could that be because it's only available to small businesses and not private families?

Next question: The first thing I have to do, if I pick Affinity Gold Preference (which I think I will) is find a Primary Care Physician. Unfortunately my current PCP doesn't not take that plan. In fact the only plan that he does take that coincides with the plans my surgeon takes is United Compass, and, as I said, I can't find it on the website and the person I spoke to on the phone of the Exchange said she couldn't find it either.

So --- I need a new PCP, I'm presuming.

I live in the East Village and it would be nice if, for a change, I could get a doctor whose office is not that far away from my home.

I'm looking at the Provider search function at the Affinity website and I'm finding many many PCPs (a good thing, I guess), but how to wade through them? Does anyone know of the Sidney Hillman Center? There seem to be good doctors there.

Or have any knowledge of any PCPs who take Affinity Gold Preference?

(I guess I could have shortened my question to that last line. Sorry)
posted by DMelanogaster to Health & Fitness (4 answers total)
Best answer: I can't answer any of your questions specifically, but Community Health Advocates helps people navigate changes to their health insurance as a result of the ACA. I believe their services are free, and they have a few offices in Manhattan.
posted by amicus at 11:11 AM on August 17, 2014

FYI...I'm not sure how the NY Exchange is set-up, but we recently ran into a similar issue with our son's insurance (private-pay policy expires in September, has to go with the Fed exchange) and we discovered that this was outside the open enrollment period.

There are only a handful of allowable circumstances where one can buy an exchange policy outside the open enrollment period. It took my wife hours on the phone in a conference call between her, an independent insurance broker and an exchange rep before the rep was convinced that our son's situation was an allowable exception.

Hopefully NY's exchange is more amenable.
posted by Thorzdad at 3:31 PM on August 17, 2014

I can't find a way to access the plan listings on the New York marketplace site without registering. There is some general information on UnitedHealthCare's Compass plans on their website here.

It may be that UHC's exchange plan(s) in New York use the UHC "Compass" network without that word appearing in the plan name. Companies like United have multiple provider networks, each having different varying terms, requirements, and rates of payment for the providers. Some providers may be participating in other UHC networks, but not their Compass network, and vice versa. It sounds like the providers you're most interested in are in UHC's Compass network though.

One NYC insurance broker has some information online that says: On Exchange, the UHC plans use the Compass Network. Off Exchange, Individuals have access to the Liberty network. All plans require referrals, no freedom or out of network coverage available. If this is correct, it could explain why you're seeing "United" offered on the exchange, but not "United Compass." But don't assume this without verifying it.

The NY Exchange has a lookup tool to find insurance brokers (commission-paid agents) and navigators (unbiased, grant-funded assistance) near your location. As an example, it allows you to search for insurance brokers affiliated with UnitedHealthCare, and they should be able to answer your questions about their Compass plans' availability through the exchange. The Navigators can help you with this, too.

Note: using the Exchange is important if you're eligible for premium subsidies. If you're not, you can get the same plans through an insurance broker.
posted by Snerd at 4:37 PM on August 17, 2014 [1 favorite]

Response by poster: This:

'On Exchange, the UHC plans use the Compass Network."

is SUCH an important sentence! it's what my insurance broker told me today.

It's also interesting that I can get the same plan out of the exchange. Before we formed our S-Corp, premiums for individual subscribers cost something like $3000 a month! (which is why we formed our two-person "group" in the first place). So there must be some sort of subsidy going on, not for individuals (I get no subsidies - my income is too high), but for the "groups" of strangers that are subscribing on the Exchange, even if we're not low-income?

(whether or not you can answer this question, thank you so much for your responses!)
posted by DMelanogaster at 2:33 PM on August 18, 2014

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