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NY State of Health - For Individuals    & Families

This section provides more information about what NY State of Health means for New York City residents.

Who can use the NY State of Health?
What is a health insurance Marketplace?
What you can expect when using NY State of Health?
When can you get insurance in NY State of Health?
What does NY State of Health offer?
How to get health insurance in NY State of Health?

Who can use the NY State of Health?

Although most New Yorkers can buy coverage on NY State of Health, it is geared towards individuals under age 65 who do not have coverage through an employer.

  • Self-employed workers, including sole proprietors, will be able to buy insurance on the individual portal of NY State of Health.
To use NY State of Health, you must live in NY state, be a citizen, national, or immigrant lawfully present in the U.S. , and not be incarcerated.
  • Undocumented immigrants cannot buy private coverage in the Marketplace, although there are other coverage and care options available to them. Click here to learn more.
  • Small businesses located in New York will also be able to purchase coverage in NY State of Health’s Small Business Marketplace. For more information on coverage for small businesses, click here.
  • There are free or low cost care options available for people in NYC who cannot get coverage through the marketplace. Click here to learn more.

What is a health insurance Marketplace?

An Exchange – also referred to as a “marketplace” - is an organization that helps residents and small businesses obtain health insurance.

Under the Affordable Care Act, there will be a new marketplace in each state.

In NY, the Official Health Plan Marketplace is called NY State of Health. It is run by the state.

  • New York State of Health will offer multiple plans from different carriers and is a one stop shopping destination for health insurance coverage.
  • It will allow consumers to compare plans and purchase coverage.
  • Some individuals who buy private coverage through the Marketplace can get tax credits and subsidies to lower their health insurance costs.
  • NY State of Health will also enroll individuals in public health insurance.

Small businesses can buy coverage in NY State of Health, too.  To learn about how NY State of Health will serve small businesses and their workers, click here.

What you can expect when using NY State of Health?

When applying for insurance, you will be screened to see what coverage options best fit your needs.
The Marketplace can tell you if you qualify for public health insurance such as Medicaid or a tax credit to lower your private insurance costs.

  • If you do not qualify for Medicaid, NY State of Health can tell you if you can get financial help with paying your premiums. There are two types of financial assistance available in the Marketplace:
    • Premium Tax Credits (PDF) (also called premium assistance) – these credits can be used to lower your monthly premiums. The federal government can pay the credits in advance (pdf) to the insurance company each month so that you pay less each month for insurance. You can also choose to get the premium tax credit as a refund on your tax return at the end of the year when you file your taxes.
    • Cost-sharing Reductions (PDF)- this type of help will limit on the amount of your out of pocket costs (these are health care costs beyond your monthly premiums, most often co-pays and deductibles) you will have to pay when you receive medical treatment.

Employer-sponsored Coverage & the New York Sate of Health (NYSOH)

If you already have insurance through your spouse or employer, you can still buy a private plan in the New York State of Health (NYSOH). However you may not qualify for the Premium Tax Credit (PDF).

That said there are two (2) exceptions:
  1. If the cost for you to get employee-only coverage from your employer is more than 9.5% of your household income, you and your family may be able to get coverage in the Marketplace and receive financial assistance.
  2. If your employer’s coverage is inadequate, meaning it pays less than 60% of the cost of covered benefits, you and your family may be able to get coverage in the Marketplace and receive financial assistance.  Your employer should tell you if the coverage they offer is inadequate.

Also, children under 19 who have health insurance through a parent’s job and drop that coverage to enroll in the Marketplace may be subject to a waiting period before they can enroll in Child Health Plus

When can you get insurance in NY State of Health?

You can apply for insurance in NY State of Health at any time during the year, but you can't always enroll in a plan.

If you are eligible for public health insurance, you can enroll right away, any time of year.

You can only enroll in private health insurance during “open enrollment”.

Every year there will be an open enrollment period when you can enroll in coverage for the first time or switch plans.
  • The first open enrollment period was from October 1, 2013 through March 31, 2014.
  • The next open enrollment period will be November 15, 2014 through February 15, 2015.
  • After that, annual enrollment periods will occur October 15th through December 7th of each year.

You can only enroll in private insurance outside of the open enrollment period if you have a “qualifying event”, which allows you to enroll during a “special enrollment period”.

  • Special enrollment periods are not during set times throughout the year. They are time-limited.
  • These periods start when you experience a “qualifying event”- such as a change in marital status, the birth or adoption of a child, moving out of state, or the loss of job-based insurance.
  • Most last only thirty (30) days from the date of a qualifying event.  If the event is the loss or gain of public health insurance then the special enrollment period is sixty (60) days.
  • You must enroll within this time period or else you'll have to wait until the next open enrollment period.

Once the Marketplace determines that you are eligible to purchase coverage, you cannot be denied by a specific plan. In addition, your premiums will not change during the plan year.

What does NY State of Health offer? - Shopping, Applying, and Enrolling in Coverage

NY State of Health helps you shop and apply for health insurance. You can:
  • Compare and contrast plans online to see which plan best fits your needs.
  • Receive unbiased help with selecting, applying for, and enrolling in health insurance.
  • Fill out one application to apply and check for all coverage and cost saving options available in the Marketplace.

Through NY State of Health, you can enroll in public or private health insurance

  • Adults under age 65 who are not blind and do not have a disability can enroll in Medicaid, a free public health insurance program, if they meet the eligibility requirements.
  • Children under age 19 in families whose income is below 400% of the federal poverty level (in 2013, that’s about $94,200 for a family of four) can enroll in free or low-cost Child Health Plus, a public health insurance program.
  • Adults under 65 and children who do not qualify for public health insurance can enroll in private health insurance plans that meet state and/or federal requirements. All of these private plans will:

    • offer a comprehensive level of benefits that includes 10 categories of “essential health benefits.”
    • offer one of 4 levels of coverage, described by a “precious metal” category of coverage; Bronze, Silver, Gold, and Platinum. These metal levels describe how much of covered health care costs the plan is expected to pay on average.
    • limit the total amount you have to pay out-of-pocket costs for the covered care you get each year.
Lower cost plans for young adults and some other individuals who don’t have other affordable coverage options.

Health plans will be able to offer a lower cost “catastrophic plan” to people who are under 30 or who are exempt from the requirement to purchase coverage based on either the affordability or hardship exemptions.

How to get health insurance in NY State of Health?

You can fill out and submit an application for insurance in  NY State of Health through one of four ways:

On the Marketplace’s website
  • To submit an application online you can fill it out through the NY State of Health  website. The website will allow you to partially fill out an application, save it, and then come back and finish the application at a later time, during the open enrollment period. To fill out an application for coverage through the online Marketplace click here.
  • Over the phone by speaking to a representative from the NY State of Health’s call center. The number for the call center is 1-855-355-5777.
  • By working with a certified Navigator/ Assistor or broker to complete an application in-person  
    • You can get free one on one in-person assistance with filing your application from a Navigator or, In-Person Assistor (IPA) 
      • These assistors are paid by NY State of Health and are required to provide you with impartial and accurate information to help you make the best decision for your health care needs and budget.
      • Use this map of IPA/Navigators to find an organization in your area with staff person that can help you with applying for coverage.
    • You can also get help filling out and submitting an application from an agent,  broker or certified
      • Agents, brokers and certified application counselors are required to be knowledgeable about all coverage options but they are not paid by NY State of Health and they may not be totally independent.  For example, brokers and some certified application counselors are paid by an insurer, so they may want to encourage you to enroll you in certain plans.  All brokers and certified application assistors must tell you about these types of conflicts of interest.
    • NY State of Health will provide a list of certified brokers on its website.
  • By mailing in an application
    • You can fill out a hard copy of an application and mail it to NY State of Health.

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