Health Insurance Strategies

Group Project 1

Group 4

HNSC 4300 EW-6 (55049)

November 10, 2021

Group Members: Fifa Atef, Paola Hernandez, Hooria Raza & Julia Wang
2

I.  Finding Health Insurance 

1.  Based on this single adult income level and the information provided above, what type if

any health insurance will this individual qualify for? Can this individual qualify for any

type of government or subsidies to help with health insurance coverage? Can the Patient

Protection Affordable Care Act (Obama Care) be used to help this individual receive

healthcare?

Due to age and income criteria, the individual does not qualify for government-based

Medicare or Medicaid plans, which require a minimal age of 65 and annual income of $17,609,

respectively, for eligibility. She is also not eligible to the federally funded program Essential

Plan, which covers 95% of total premium subsidy and cost-sharing (1) for individuals earning up

to $25,520 annually who do not qualify for Medicaid services (2). However, she is qualified for

individual private insurance, such as the Bronze Leaf offered by HealthFirst, with a monthly $17

premium. The ACA can be used to protect the individual from being charged higher premiums

due to pre-existing conditions of hypertension and receive free preventive care (3)

2. Even if this individuals do not specifically qualify for all of them, in general what are the

health insurance options that are available to low-income people in NYC? Describe the

some of the different program/plan, including whether they are administered by NY State,

NY City, Local Community Based Health Centers/Clinics or any other entities. What are

the eligibility criteria for them?

NY State offers the Medicaid and Essential Plan programs. Medicaid is a social welfare

program, expanded under the ACA to 138% below FPL, that manages health insurance care
3

plans for low-income eligible US citizens or individuals meeting immigration status criteria and

offers a full range of health services, such as physician visits, lab tests, medication and dental

care. As of today, the income criteria cutoff for a single person household is $17,609, however it

is annually changed (4). For individuals that are not eligible for Medicaid, the NY State also

funds the Essential Plan for adults between 19-64 years old meeting citizenship or immigration

status requirements, with income cutoff of $25,520 for a single person household (2), and Child

Health Plus, for children under 19 years old, with no income nor immigration status

requirements.

3. What is the best way for this individual to get coverage? Write about the situation this

individual will face, including why the plans identified to provide health insurance for this

individual may not work. What (if any) are some other options?

From all the possible coverage options, the individual would benefit more from

purchasing private individual insurance. She is ineligible for Medicaid or government-based or

funded programs due to income criteria, and employment-based insurance is not a benefit

provided by her employer. The cost of constant out of pocket services could surpass the premium

of private insurance. In addition, she requires constant care through regular physician's visits,

which would be offered for free under the ACA in an insurance plan, and medication

prescription coverage to manage and control her hypertension and prediabetes conditions. The

challenges she would face include if the copayment costs for drug prescription for the chosen

insurance plan would fit within her budgetary allowance determined by the remaining disposable

income. As an alternative, she could enroll in NY Uninsured Care Programs that provide free
4

drugs and premium payments for underinsured and uninsured residents whose incomes are below

500% FPL (5).

4. Write about the process of searching for a plan. What strategies did your group decide

upon to begin their search? Where did the search begin, identify some of the first websites

visited, if you started on the internet, what search terms did you type in? What were the

challenges your group faced in performing this? Did comprehension of some of the

healthcare terminologies posed any challenges? Approximately, how long did it take to

complete this scenario?

To find the best insurance plan that fits the individual’s needs, we first analyzed her

health status and care needs, based on her medical diagnosis of hypertension and borderline

diabetes status, income and eligibility criteria for government-funded programs Medicaid and

Essential Plan. Because her income is higher than the cutoff eligibility for a single person

household, we looked at individual plans that would financially fit within her budget. We

searched for the major health insurance providers in NY and used the NY Health Plan

Marketplace website to have an estimate of the cheapest and available plans for her (4). We went

to the provider’s websites to have a more accurate perspective of health plan costs and compared

each one based on premium, deductible, OPC and copays. We selected the plan with the lowest

monthly premium that would fall within her budget and provide the care that she needs and

searched for additional services that would help her pay for premiums and prescriptions, by, for

example, typing "underinsured health programs". The main challenge was to get used to specific

insurance terms and to know how to compare between plans and its benefits. The completion

took approximately 3 weeks to be done.

5

5. Based on the group's research, what are some of the advantages/disadvantages this

individual will face in receiving healthcare services in this manner?

Among the advantages, the individual will receive coverage for telemedicine, prenatal

and preventive care, and screening services before she meets her deductible. In addition, she

does not require a referral to see specialists within the network provider, and copays for PCP and

specialist consults are not subjected for the first three visits. This monthly premium cost of $17 is

also within her budget of $26.76. The main disadvantage is the high deductible cost for this plan,

of $4700. Therefore, diagnostic and imaging tests, physician consultations after the third visit,

and drugs are only cost-shared with Healthfirst after she meets her deductible (5), which are

beyond her budgetary allowance. However, as mentioned before, the individual could apply for

additional programs that help to cover underinsured individuals.

II: Evaluating Health Insurance Plans Public Sector Employment

1. For each of the two plans chosen, SHOW the total out-of-pocket annual health care

expenditures (the family's share of the premium, their payment for optional riders, plus

any co-pays, deductibles, and/or coinsurance - multiplied by the number of times the

services is expected to be used, including the costs for drugs that is anticipates to be paid

for over the next year).

The group must calculate the family’s total expected costs (premium, copayments x visits,

deductibles, drugs x # of Rx) with each plan and show the steps in the calculation.
6

1. Non-HMO: Empire Blue Access Gated EPO

  Amount Visits x # Total

Premium $370.98 52 $19,290.96

Co-pay for visit      

Primary care $15 12-14 $180-210

Specialist care  $15 4 $60

Outpatient dx test $0 3 $0

ER $35 5 $175

Hospitalizations $300 2 $600

Maternity service $300 1 $300

OBGYN $0 7-10 $0

Generic  $10 10 $100

Brand  $25  1 $25

Mental health  $15 24 $360

7

Deductible (out of pocket $0   $0

maximum)

Yearly TOTAL     $21,090.96- 21,120.96

(6, 7)

2. HMO- GHI HMO

  Amount Visits Total

#

Premium $383.51 52 $19,942.52

5

Co-pay for visit         

Primary care $15 12-14 $180-210

Specialist care  $15 4 $60

Outpatient dx test $0 3 $0

ER $35 5 $175

Hospitalizations $0 2 $0

Maternity service $0 1 $0

OBGYN $0 7-10 $0

Generic $18 10 $80

Brand $16  1 $16

Mental health $15 24 $360

Deductible (out of pocket $0   $0

8

maximum)

Yearly Overall Total     $20,813.52 - 20,843.52

(8, 9)

2. Which services are especially important to this family? Why? What kind of coverage

does each plan of the two plans chosen offer? Of the two plans chosen, which would be best

for the family? Why?

 Physician appointments and drugs are important services for the family. Three members

of the family have chronic illnesses, and the wife is currently pregnant, necessitating additional

monitoring. Asthma and hypertension sufferers in the family. Hypercholesterolemia necessitates

both physician supervision and prescription treatment. Regular physician visits, specialist visits,

medicines, hospitalization, and ER visits are all covered by both insurances. However, the HMO-

GHI HMO is cheaper and has a free hospitalizations and maternity service compared to the

Empire Blue Access Gated EPO, which would be beneficial for the wife.

3. For each plan of the two plans chosen, comment on the choice of providers and other

issues of importance to the family (other than the cost).

Family members require specialized, OBGYN, psychologists/therapists, and regular

appointments to the clinic and emergency hospital. Both insurances require the family member to

select a primary care physician from a list of in-network providers. Their primary care physician

will also recommend them to specialists.

9

III: Purchasing Health Insurance Through NYS Health Plan Marketplace

1.  Describe the eligibility requirements for shopping for a health plan in the New York

State marketplace? Briefly describe the various health plan available through the

marketplace for this individual and the estimated cost.

The health plan marketplace for individual ask for: SSN (or document numbers for legal

immigrants who need health insurance), birth dates, employer and income information for

everyone in your family – pay stubs from the last 30 days, for self-employed individuals, recent

tax returns or profit and loss statements –, policy numbers for any current health insurance,

information about any job-related health insurance available to your family, and list of current

doctors (to verify plan participation). 

There are several health plans available: 

The Oscar (Oscar Secure Catastrophic, ST3PCP, INN, Pediatric Dental, Dep25, Step

Tracking Rewards) costs $185, and is for preventive and wellness services, such as routine care

including screenings, check-ups, and patient counseling to prevent illnesses, disease, or other

health problems. It also includes free 24/7 calls with doctors; free preventive care such as a

checkup, flu shots, and some birth control; free prenatal care for expecting mothers; step tracking

rewards for staying active; savings for medical care in our network; no referrals required; single-

tier EPO network; and embedded deductibles. benefits include comprehensive coverage for

hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care

services such as annual check-ups & flu shots. Coverage for your child's dental and vision care,

as well as a gym reimbursement. 

10

  The Fidelis Care (Fidelis Care, Catastrophic, ST, INN, Fidelis Care HBX Network,

Pediatric Dental, 3 free PCP visits, free telemedicine) costs $214. It is a direct access to a large

network of quality providers throughout New York State. No referrals or paperwork are required

to access providers.

The Healthfirst (Health first Green Leaf, Catastrophic, ST, INN, Pediatric Dental, Fitness

& Wellness Rewards) costs $282.07. It offers complete coverage, including telemedicine (24/7

communication with a participating provider), preventive and annual check-ups, prescription

drugs, and more. No referrals required for specialists, obstetric and gynecologic services,

chiropractic services, outpatient mental health and substance abuse services, retail health

services, pediatric dental care, pediatric vision care (except from an ophthalmologist). 

The Empire (Health Plus Gatekeeper X Catastrophic ST INN Individual Network

Pediatric Dental) costs $282.80. The provider network gives access to leading doctors and

hospitals throughout our New York service area. The network includes primary care physicians

who are committed to transforming their practices to a patient-centered model of care. All

Empire plans require referrals for specialist care.

The Healthfirst (Healthfirst Bronze Leaf, ST3PCP, INN, Pediatric Dental, Dep25, Fitness

& Wellness Rewards) costs $457. It offers complete coverage, including telemedicine (24/7

communication with a participating provider), preventive and annual check-ups, prescription

drugs, and more. No referrals required for: specialists, obstetric and gynecologic services,

chiropractic services, outpatient mental health and substance abuse services, retail health

services, pediatric dental care, pediatric vision care.

2. Based on the information provided above, what type of health insurance coverage should

this individual purchase? Describe the financial assistance available if any that this
11

individual can apply for through the Patient Protection Affordable Care Act to lower the

cost of health insurance coverage? How did your group use the information on the website

to select the best health coverage for this individual?

This individual should get one of the first fourth insurance plans we described above,

which costs between $185-$284. By analyzing and comparing all insurance plans, we suggest

either Fidelis Care or Healthfirst. It is within this individual budget and offers a lot of benefits for

the member. There are some affordable public health insurances for uninsured or individuals

who cannot get coverage. The NY State of Health, under the official health insurance

marketplace, and the affordable care act offer free and low-cost public health insurance programs

for low-income New Yorkers. Most adults under the age of 65 and children must apply for

coverage through NY state of Health, operated by New York State and is the Official Health

Plan Marketplace. The Affordable Care Act and New York State require private health plans to

offer comprehensive coverage to individuals. The ACA also makes financial assistance available

to eligible residents purchasing coverage through the NY State of Health. This financial

assistance includes help paying the cost of monthly premiums and out-of-pocket expenses

including co-payments, deductibles and coinsurance (10). Enrollment in private health insurance

plans is limited to specified enrollment periods – called “open enrollment” periods. The next

open enrollment period for purchasing private health insurance starts November 15th, 2014.

Open enrollment applies both to plans sold to individuals through the NY State of Health, as well

as plans bought directly from insurance companies outside of the marketplace (10).

3. Write about the process of going to this website to purchase a health plan. Describe your

group’s experience with navigating the website to assess the various health plans available
12

for purchase for this individual. Did you have to reach out to the helpline for

assistance/guidance on navigating the website? Did any of the plan asked about pre-

existing conditions? Did comprehension of some of the healthcare terminologies and details

of the various issues posed any challenges? Approximately, how long did it take to complete

this scenario, what type of difficulties did your group experience?

We looked at the information through the NYC health marketplace. It was a little

confusing at the beginning because the website has a lot of options to look for. However, the

website explains step by step depending on what people look for. For this activity we found the

information at the homepage of the website. We clicked on the compare plan and estimate-cost

bottom. The website asked us for a zip code, so it showed the best options. Also, the website

asked you if you need insurance for family, individuals or company. We looked for insurance

according to the instructions of the question. The NYC marketplace website shows with details

every insurance depending on the zip code you enter. We only selected five options that will fit

best for our group project. For the question about The Affordable Care Act, it was more difficult

to find information because the home page only explained a little bit about the option and the act.

However, we found information searching in google about the conditions for that option. It took

us about 2 hours to figure everything out and navigate the website. We did not have to reach out

to the helpline for assistance for any health insurance coverage information. The website also has

an option for Q&A and explains every option they offer. 

4. Based on the groups research, what are the some of the advantages/disadvantages of

using the New York State health plan marketplace to purchase health coverage?
13

New York State health plan marketplace helps to know about different health insurance

coverage plans in the same place and helps to compare different health insurance plans so it

becomes easier for a person to look and decide which one will be suitable for them. Another

advantage is that you can apply for lowering the prices of your insurance coverage plans and also

through the New York State health plan marketplace you can find out if you qualify for free or

low-cost coverage from Medicaid, Child health plan or Essential plan. Moreover, New York

State health plan marketplace will check if you qualify for Insurance Affordability Programs

include Medicaid, Child Health Plus, the Essential Plan, Advance Premium Tax Credits, and

Cost-Sharing Reductions as these programs can reduce the cost of health insurance coverage

plans if the income is low (11). One disadvantage can be that sometimes not enough information

is present on the website, so the person trying to find a suitable health insurance coverage plan

has to call the helplines to get more information. However, this can be a lengthy process and

sometimes people do not have enough time for this. 

IV: Health Insurance Terminologies

To become familiar with keys terms related to health insurance. For the following terms

listed below in full sentences, briefly explain what each of the following terms means and its

application to health insurance coverage. Select and briefly explain which of the following

terms were applicable to part 1, 2, and 3 of the group project.

ACO: group of health providers that work together to achieve common health goal

Balance Billing: amount charged by the provider that is not covered by the insurance

company
14

Beneficiaries: individuals designed to receive benefits from a member of an insurance plan

CHIP: program providing low-cost insurance plan to not-Medicaid eligible children

Co-Pay: set amounts paid to medical providers to receive medical services

COBRA: law allowing individuals who were enrolled in employment-based insurance and

are no more eligible to continue insurance plan for a limited period of time

Coinsurance: cost-shared amount paid for a service after deductible is met

Claim: request submitted to insurer for payment or reimbursement of covered services

Deductible: amount paid for services before payment by insurance company

DGR: classification system to categorize patients with similar diagnoses for cost control

DSH Payment: supplemental payment program that reimburses hospitals for

uncompensated care costs in inpatient services, beneficiaries and uninsured individuals

ERISA Plans: voluntary plans by employers that meet minimum federal standards set by

ERISA law to protect employees

EPO: managed care plan offering coverage of services solely for providers within plan’s

network

Formulary: list of prescription (brand and generic) drugs covered by health plan

FEHB Program: employer sponsored insurance program that provides health care plans

and benefits to employees

15

FSA: pre-taxed account with money for out-of-pocket medical expenses

HMO: type of insurance plan that limits coverage of services to physicians within

organization's network 

HSA: pre-taxed account for out-of-pocket medical expenses for individuals with HDHP

HRA: employer-funded group health plan with tax-free reimbursements for qualified

medical expenses

HDHP: health plan with higher deductible than traditional plans but lower monthly

premiums

Health Insurance Marketplace: resource that provides comparison of healthcare plans,

information about insurance, eligibility to Medicaid and CHIP and enrollment in insurance

plans

IHS: agency providing federal health services to American Indians and Alaska natives 

IPG/IPA: type of HMO that allows practitioners to provide services for patients that are not

enrolled in HMO

MSSP: program that allows providers and suppliers to create an ACO to improve quality of

care for FFS beneficiaries and reduce unnecessary costs

MEDIGAP: Medicare supplement insurance provided by private companies to cover costs

not covered by Medicare

16

MedPAC: independent agency that advises the congress on issues that affect Medicare and

analyzes care access and quality

MACRA: created the Quality Payment Program that gives bonus payments for APMs

participation, streamlines multiple quality programs under MIPS, and changed clinician

rewarding by Medicare

MIPS: rewards clinicians based on performance in quality, interoperability promotion,

activity improvement and costs

APM: gives added incentive payments to physicians that provide quality improvement and

cost-efficient care

MHS Tricare: military health coverage program providing care to active and retired

military members and their dependents

RRP: Medicare purchasing program encouraging improve of hospitals' communication and

care coordination to increase discharge plans and reduce readmissions

RBRVS: physician payment system to determine amount that medical providers should be

paid

Rider: amendments and changes to basic insurance policy to provide additional coverage

options or restrict and limit coverage

Reimbursement for Health Services: payment received by medical providers from insurer

or government payer for giving medical services

17

Self-Funded Health Plan: self-insurance plan in which employer pays most of the cost of

benefit claims

Short Term Insurance: health insurance that covers a period of 30 to 90 days

Site of Service Differential: describes reimbursement methodology and recognizes if a

physicians’ practice expense is lower from using resources from facility setting rather than

of their own

Stop-Loss Coverage: insurance policy by self-funded health plan for protection against

catastrophic medical expenses

Supplemental Healthcare Insurance Plan: additional plans that cover amounts beyond

basic medical coverage or costs not covered by primary insurance (copayments,

coinsurance, deductibles)

Underwriting Health Insurance Policy: process used by insurance companies to try to

figure out the patient's health status when they apply for health insurance coverage to

determine whether to offer them coverage, at what price, and with what exclusions or limits

VBP: strategy to improve quality and value of health services received and patients'

experience, through value-based payment

Veterans Health Administration: provides medical care and social support services to

American veterans. 

Some of the terminologies used in this project: 

18

The definitions used in the part 1 are co-pay, to determine the amount shared with

Healthfirst for physician consultations after deductible; coinsurance, to determine the

amount shared with the insurance company for diagnostic and imaging tests after deductible

is met; and deductible, to determine the amount needed by the individual before cost-

sharing with Healthfirst. In the second part of this assignment, the term Exclusive Provider

Organization (EPO) was used to manage a care plan that exclusively covers services

performed by providers in the network of the insurance plan. The third part used the term

Health Insurance Marketplace to find healthcare plan comparisons, insurance information,

Medicaid and CHIP eligibility, and insurance plan enrollment.

19

References: 

1. Schneiderman E. In Defense of New York State’s Essential Plan,’  We’re

Suing the Trump Administration. Health Affairs, 2018.

https://www.healthaffairs.org/do/10.1377/hblog20180206.483547/full/

Accessed November 7, 2021.

2. New York City Office of Citywide Health Insurance Access. Essential Plan.

https://www1.nyc.gov/site/ochia/coverage-care/essential-plan.page Accessed

November 7, 2021.

3. New York City Office of Citywide Health Insurance Access. Affordable Care

Act. https://www1.nyc.gov/site/ochia/your-rights/affordable-care-act.page

Accessed November 7, 2021.

4. New York City Office of Citywide Health Insurance Access. Medicaid  

https://www1.nyc.gov/site/ochia/coverage-care/medicaid.page Accessed

November 7, 2021.
20

5. Healthfirst. Healthfirst: Bronze Leaf.

https://assets.healthfirst.org/pdf_8716c07bcacc5b28128d3d67d1435f1e?_ga=2.

103444224.1805093328.1636208769-

201278915.1636208769&v=1106142617 Accessed November 7, 2021.

6. Empire Blue. Empire Blue Access Gated EPO.

https://www1.nyc.gov/assets/olr/downloads/pdf/health/summary-of-plans-

empire-access-gated.pdf Accessed November 7, 2021.

7. Empire Blue. Summary of Benefits and Coverage.

https://www1.nyc.gov/assets/olr/downloads/pdf/health/sbc-empire-blue-access-

gated-with-rx.pdf Accessed November 7, 2021.

8. New York City Office of Labor Relations. GHI HMO

https://www1.nyc.gov/assets/olr/downloads/pdf/health/summary-of-plans-ghi-

hmo.pdf Accessed November 7, 2021.

9. New York City Office of Labor Relations. GHI HMO Basic With Rx

https://www1.nyc.gov/assets/olr/downloads/pdf/health/sbc-ghi-hmo-basic-

with-rx-2020- 2021.pdf Accessed November 7, 2021.

10. New York City Office of Citywide Health Insurance Access. Health Insurance

Under Affordable Care Act

https://www.nyc.gov/html/hia/html/get_health_insurance/accessnyc_info.shtml

Accessed November 7, 2021.

11. New York State of Health | Health Plan Marketplace for Individual and Small

Business Health Insurance. Nystateofhealth.ny.gov.

21

https://nystateofhealth.ny.gov/individual?lang=en. Published 2021. Accessed

November 9, 2021. Accessed November 7, 2021.