individuals & frequently asked questions from families
why should i buy a health plan through the marketplace?
because you’ll benefit from the great features listed below. all of them are found only in new york state of health:
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- Non-Marketplace Vs. Marketplace Health Insurance
- choice and value: Compare health plans side by side to find the one that’s right for you.
- Financial support: See if you can get help lowering the cost of your premiums.
- In-Person Assistance: Enroll with the help of experts who are trained and certified by the New York State of Health.
- Online Registration: Use our quick and easy online registration process.
- phone support: talk to call center assistants who will answer your questions.
- public programs: sign up for medicaid or child health plus if you qualify.
- what kind of medical services do I need?
- Are there prescription medications I need to take?
- Are there doctors and other health care providers you prefer?
- must live in new york
- must be a US citizen, national, or lawfully present immigrant (different immigration rules may apply if eligible for child health plus or nys medicaid based on income)
- cannot be currently incarcerated. (Different rules may apply if you are eligible for Medicaid based on your income.)
- You cannot apply for coverage of nursing home care or care provided in a residential treatment facility for children and youth, a developmental facility, or an intermediate care facility for persons with developmental disabilities.
- social security numbers (or document numbers for legal immigrants who need health insurance)
- dates of birth
- employer and income information for all members of your family
- policy numbers of any current health insurance
- information about any OB-related health insurance available to your family
- your spouse, if married
- any child in your care who lives with you
- your partner, who lives with you
- anyone you list on your federal income tax return
- no cost sharing, such as deductibles or copays, if family income is below 300% of the federal poverty level and the person is enrolled in a qualified health plan in the marketplace
- the ability to change a health plan once a month, if they are enrolled in a qualified health plan
- exemption from payment of individual responsibility if they do not maintain health insurance coverage.
- your eligibility for medicaid or child health plus
- the amount of financial assistance you will receive for your monthly health insurance premium
- the amount of financial assistance you will receive for your out-of-pocket costs when you use health care services
- a denial of a special enrollment period; and
- if we make a timely eligibility determination
- If you have Medicaid, contact the Office of Administrative Hearings at www.otda.ny.gov/oah/ or 1-800-342-3334 to appeal coverage decisions.
- if you have child health plus or are enrolled in a qualified health plan, contact your health plan to appeal coverage decisions. You can find information about health insurance complaints and appeals on the Department of Financial Services website at http://www.dfs.ny.gov/consumer/chealth.htm
how should i prepare to buy a health plan through the marketplace?
Think about your coverage needs. ask yourself these kinds of questions:
Where can I get help understanding my insurance options in the marketplace?
Any state-certified health expert can guide you through the enrollment process. they can help you enroll in a health plan that is right for you based on your needs. They can also help you determine if you can get help lowering the cost of coverage. You can get help online, in person where you live or work, and by phone. you choose what works best for you. click here to find one of our experts who can help you.
Can I buy insurance through the market if I already have a serious health problem?
yes. The amount you pay for a health plan will not be affected by your health status. this means that you cannot be charged more for your health problem. it also means you won’t have to wait to get the coverage you need.
what if I decide to go without health insurance coverage?
People who don’t get a health plan may have to pay a tax penalty to the federal government. but in some cases the penalty will not have to be paid. For more information, speak to one of our helpers.
Who can get coverage through the Marketplace?
To buy from the market, you:
what if I speak or read in a language other than English?
new york is a diverse state with many people who can speak or read a language other than english. Call the Marketplace at 1-855-355-5777 for more information or help applying for coverage in your language. all help is free.
why do I need to provide a social security number (ssn)?
The marketplace needs social security numbers for everyone who has one and applies for health insurance. We use ssns to verify federal and state data sources to help speed up the application process. Providing your social security number can be helpful even if you don’t want health coverage. If you don’t have an SSN, call the Social Security Administration at 1-800-772-1213 or visit www.socialsecurity.gov to see if you can get an SSN and apply for one.
can I give someone else permission to get information about my application?
Anyone can call us with general questions, but we can’t discuss specific information about your application with anyone else unless you give us permission to do so. You can give a trusted friend, relative, business associate or attorney permission to talk with us about your application and to act on your behalf in matters related to your application. this person is called an authorized representative. You can call 1-855-355-5777 to find out how to name someone as your authorized representative.
What do I need to apply for coverage through the Marketplace?
We ask about your income and other information about you to tell you what coverage you qualify for and if you can get help paying for it. We keep all information you provide private, as required by law. For all of you seeking help paying for your health insurance through the Marketplace, things to know:
who should I include in my application?
Your income and family size help us decide which programs you qualify for. Include these people on your application for health coverage:
You don’t have to file taxes to apply for health insurance coverage for the Marketplace. anyone else who lives with you will need to apply on their own if they want insurance. not everyone has to live at the same address to submit the same application.
why is the market asking about race and ethnicity?
As part of the health insurance application process, there are optional questions about the race and ethnicity of each applicant. You don’t have to answer these questions, but answering them can help us better serve your community. Giving us this information will not affect your eligibility, plan choices, or access to programs.
what benefits do American Indians or Alaskan Natives get through the market?
american indians and alaska natives recognized by the us. The government may qualify for special health care cost sharing and other benefits as a result of the Affordable Care Act. these include:
For more information, click here.
Can I still get health insurance if I have a disability or chronic illness?
You may still qualify for health insurance if you have a disability or chronic illness. Chronically ill people include people who are unable to work for at least 12 months due to illness or injury. they also include people who have an illness or disability that has lasted or is expected to last at least 12 months. the market will make sure you get the right services. this may involve referring your application to our local departments of social services for further assistance.
what if I need coverage for nursing home care?
You can’t apply for nursing home care coverage through the Marketplace. You must apply for Medicaid coverage for nursing home care through your local department of social services. If you need help finding contact information for your local department of social services, call the ny state medicaid helpline at 1-800-541-2831 or visit the ny state department of health website at http://www.health.ny.gov/health_care/medicaid/ldss.htm. please note: if you already have coverage through medicaid or an essential plan through any health status, you may qualify for coverage of nursing home care for a limited time through your health plan. contact your health plan for more information.
what if I need coverage in a residential treatment center for children and youth, a developmental center, or an intermediate care facility for people with developmental disabilities?
An application for Medicaid can be completed after you are admitted to a residential treatment center for children and youth, a developmental center, or an intermediate care facility for people with developmental disabilities. For assistance with the application, please contact the director of the facility where you are located.
what is the address confidentiality program?
The Address Confidentiality Program is administered by the State Department for Victims of Domestic Violence. For more information on this program, visit http://www.dos.ny.gov/acp/.
I’m moving to new york in the next few months. can i apply for health insurance in new york now?
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You can apply for health insurance through the Marketplace if you’re moving to New York for a job or to find a job within the next 90 days. however, you cannot enroll in a health plan until you have moved to new york state and provided us with your new york address. You can update your address by logging into your marketplace account or by calling us at 1-855-355-5777.
Can I still apply for health coverage through the Marketplace if I have other insurance?
You and your family may still be eligible for health coverage even if you have other health insurance. Based on the information you give us about your other insurance, the Marketplace will see if you can get help paying for your health insurance coverage.
Do I have to file taxes to get help paying for health insurance?
Each program has its own rules regarding filing taxes. one of the eligibility criteria for an advance premium tax credit is that you must file taxes and, if you are married, you must file a joint return. To determine which program you and your family may be eligible for, we need to know the filing status of everyone on your application for the next tax year. If someone is married and will file a joint return, we need to know who they will file with. We will also need to know about any dependents you plan to claim. You must also tell us if you or other household members will not be filing tax returns. To be eligible for an advanced premium tax credit, you must file taxes, and if you’re married, you must file a joint return.
How does my filing and filing status affect my eligibility for financial assistance with health coverage?
We must ask about filing status and filing status as part of the application process. To qualify for the premium tax credit, most married people who apply through the Marketplace must file their federal taxes jointly. however, there may be situations where married individuals qualify without filing jointly. You may qualify for a premium tax credit if you were legally separated at the end of the year and have a court decree of separation or divorce. signing and filing a separation agreement with the court is not a decree. You may also qualify for the premium tax credit if you are married but living apart from your spouse and meet the requirements to file as head of household. You should consult a tax advisor or the Internal Revenue Service to determine if your situation exempts you from the requirement to file a joint return to receive a premium tax credit. If you find yourself in one of these situations, call the Marketplace at 1-855-355-5777 for more information.
Can I still get a tax credit if I’m claimed as a dependent on someone else’s tax return?
Eligibility for advanced premium tax credits is based on a variety of factors, including filing status. if you will be claimed as a dependent on someone else’s tax return, everyone’s income on that tax return will be considered in determining eligibility. You can’t get an advance premium tax credit on your own if you’ll be claimed as a dependent on someone else’s tax return.
why does the market need to know how much money i make?
Eligibility for help paying for health insurance is based on a variety of factors, including how much money you plan to earn in the next year. this includes income from a job, as well as other types of income, such as unemployment benefits and social security.
I recently dropped my employer’s coverage because it was too expensive. is my child still eligible for child health plus?
Children who were previously covered by employer-based coverage who voluntarily terminated may be subject to a 90-day waiting period before they can enroll in child health plus, unless the child meets a of waiting period exceptions.
can my child still enroll in child health plus if i have health insurance through the new york state health insurance program (nyship)?
state health benefit plans provide health insurance through the new york state health insurance program (nyship). Coverage is offered to employees/retirees of the New York State Government, the State Legislature, and the Unified Court System. some local government agencies and school districts also choose to participate in nyship. if you’re not sure, check with your employer. if her child has access to state health insurance benefits through nyship, she will not be able to enroll in child health plus.
Do I qualify for premium tax credits if my employer offers a health plan that meets the minimum value standard?
An employer-sponsored health plan meets the “minimum value standard” if the health plan’s share of the total allowable benefit costs covered by the plan is no less than 60 percent of those costs. If your employer offers a health plan that meets the minimum value, then you don’t qualify for premium tax credits.
Can I still apply for health coverage through the Marketplace if my employer offers health insurance?
You can still apply for health insurance through the Marketplace if your employer offers health insurance. If the insurance offered by your employer doesn’t meet the minimum value or isn’t affordable, then you may be eligible for premium tax credits to help pay for health insurance you buy through the Marketplace. minimum value means that the health plan’s share of the total allowed benefit costs covered by the plan is not less than 60 percent of those costs. unaffordable, in this context, means that the employee’s portion of the premium for the employer’s individual plan is more than 9.5% of the employee’s household income.
Am I eligible for health insurance if I’m incarcerated?
If you are incarcerated (except for pending disposition), you are not eligible to purchase health insurance through the Marketplace. however, you may be eligible for public health insurance programs such as Medicaid during this time. During incarceration, Medicaid coverage is limited to inpatient hospital stays provided off correctional facility grounds. The correctional facility is responsible for all other medical care and treatment provided to you.
what if I can’t afford health insurance or don’t want to buy health insurance for another reason?
Certain individuals may qualify for an exemption from the federal mandate to have health insurance. If you are approved for an exemption, you will not have to pay a penalty to the Internal Revenue Service for not having health insurance. you can find information about exemptions in the market.
I hardly ever get sick. Are there any health insurance plans that only provide coverage for critical illnesses?
People under 30 and some people who can’t afford a more comprehensive health insurance plan can purchase a type of health insurance plan called “catastrophic coverage.” Catastrophic health plans have lower monthly premiums than traditional health insurance plans, but have much higher out-of-pocket costs. If you are over the age of 30, you will first need to get approved for the hardship exemption. you can find more information in the market.
what is the premium tax credit?
The premium tax credit is financial assistance provided by the federal government to help you and your household pay the monthly premium for the qualified health plan you enrolled in the Marketplace. this assistance is only available to health plans in the marketplace.
how can i use the premium tax credit?
The premium tax credit can be used “in advance.” This means that the federal government will send the amount of the premium tax credit that you choose to use to help pay your qualified health plan’s monthly premium. If the advance premium tax credit does not cover your entire monthly premium, you will need to pay the remaining amount. You can choose to use all, part, or none of the tax credit. If there are household members who want to enroll in a different plan, you can allocate the tax credit amount among household members.
How will changes in my income or family size affect my premium tax credit?
Changes in your income and family size during the coverage year may increase or decrease the premium tax credit you qualify for. When you file your federal income taxes for this year, the IRS will look at the annual income reported on your taxes and compare it to what you told us on this application that you expect your income to be for the year. Since the premium tax credit you get depends on your yearly income, the IRS looks at the premium tax credit you earned in advance and compares it to what you can receive when you file your taxes.
If the advance premium tax credit you get for the year is less than the tax credit you’re entitled to when you file your taxes, you’ll get the difference as a refundable credit when you file your federal taxes.
If your prepayments for the year exceed the amount of your credit for which you are eligible, you must repay the excess prepayments with your tax return. If you experience any changes in your income or family size, you should update your Marketplace account or call customer service at 1-855-355-5777.
How can I find a health plan in the marketplace for myself or my household members?
Based on the health insurance program you and/or your household members qualify for, the Marketplace will show you the health plans you can choose from. We will provide you with information about the health plan, including the monthly premium, metal tier, type (i.e., medical or dental), cost sharing such as deductibles or out-of-pocket costs, covered benefits and services, and your quality rating.
Can I search for doctors, hospitals, or facilities in the health plan’s network?
Yes, you can look to see if your current doctors or the facilities where you receive health care services are part of a plan’s network of providers. Sometimes the plans your provider accepts, or the “network” they are in, will change. It’s always best to check with your provider and health plan first. We strongly recommend that you call your doctors, hospitals, other facilities, and health plans directly before completing the plan selection process.
can members of my household be in the same health plan or a different one?
You and your household members may be in the same health plan or a different one, depending on how you want to cover them through the health plan. For example, a couple may choose to enroll in the same health plan for simplicity or be in different plans because each person may have different health care needs. the cost of premiums and cost sharing will vary depending on the option you select.
How do I pay the health plan premium?
You must pay the first month’s premium for your coverage to be effective and you can start using health care services. the marketplace does not accept premium payments for health plans for individuals and families. Your health plan will send you information on how to pay this premium, or you can contact them directly.
what are the “metal levels” of the plan?
the marketplace offers four main types of qualified health plans: bronze, silver, gold and platinum. Each type of plan differs in the percentage of health care costs that a plan would pay for the average person. for example, the bronze level plan will pay 60% of all health care costs for an average person and people who enroll in this plan level will pay 40% of costs. health plans at the platinum level will cover 90% of health care costs, with the individual paying the remaining 10%.
what if I disagree with a determination made by the market?
You can call us at 1-855-355-5777 (tty: 1-800-662-1220) to discuss your concerns and we will do our best to help you. If you are not satisfied with the outcome of the informal resolution process, you may request a formal appeal, if the time to request an appeal has not expired. Or you can ask us for an appeal without using the informal resolution process.
what is an appeal?
An appeal is a formal request to have your eligibility determination reviewed because it disagrees with the one made by the Marketplace. You can request an appeal for yourself and any member of your household who has also applied for health insurance.
once you request an appeal, the marketplace will schedule a hearing. A hearing is a formal discussion where you will have the opportunity to explain why you disagree with the eligibility determination we have made. an impartial hearing officer will conduct your hearing. If you have documents that you think would help your appeal, you can bring them to the hearing. During the hearing, you can also explain why you think we made a mistake.
what can I appeal?
You can appeal determinations made by the marketplace, including:
Where do I go to appeal a decision about my health care services?
The Marketplace cannot accept appeals about health care services, such as the types of health care benefits your plan offers, access to doctors or specialists, or denial of prior authorization for services.
Are there time limits for filing an appeal request?
yes, there are time limits. You generally have 60 days to request an appeal. Once the Marketplace receives your appeal request, we’ll review it and let you know what happens next.
where do I go for my hearing?
We conduct all hearings by phone and will call you at the phone numbers you provided in your Marketplace account. If you want us to call you at a different number, you can give us that number in your Marketplace account or when you call us to request a hearing.
When you ask for a hearing, you can tell us what day of the week and time (morning or evening) works for you. We will do our best to schedule your hearing on a day and time that is most convenient for you. After we receive your appeal request, we will send you a scheduling notice to let you know when we will call you for your hearing.
what if I need special assistance or accommodations for my hearing?
You may request special assistance or accommodations for your hearing. this includes language assistance (such as translation from English to another language) and accommodations for any hearing impairments.
can I have someone help me at my hearing?
yes. You can ask a lawyer, family member, or friend to help you through the appeal process. If you think you need a lawyer, you can find one free of charge by calling your local legal aid, legal services office, or local bar association. you can also represent yourself.
If you want help with your appeal, you may designate a person or organization to act as your authorized representative. your authorized representative receives the same appeal notices and other communications that you receive.
what can I do after I submit my appeal request?
While you’re waiting for your hearing to be scheduled, we can help you try to resolve your issue informally. You may also provide new information or documents to help us understand your concerns during the informal process. to do so, you can call us at 1-855-355-5777. If we have resolved your concerns during this informal process, we will work with you to withdraw the request.
Can I continue my coverage during the appeal process?
yes, but it is optional. If you are enrolled in a Medicaid, Child Health Plus, or Qualified Health plan, you may be able to continue the same coverage or amount of financial assistance during the appeal process. Financial assistance includes help you received to pay your health insurance premiums or to lower your out-of-pocket costs when you use health care services.
If you have Medicaid, you need to act quickly. You have ten (10) days from the date of your eligibility determination notice to ask us to continue your Medicaid during your appeal process.
How will the appeal decision affect me or others in my household?
Depending on the appeal decision, you may have to pay back some or all of the financial assistance you received during the appeal process. If we determine that other people in your household are eligible for health insurance through the Marketplace, your eligibility may also change. the marketplace will notify you of the changes and redetermine eligibility for you and your household, if applicable.
what do I do if I no longer want to appeal?
If you have requested an appeal and believe it is no longer necessary, you may withdraw your appeal request. call the marketplace at 1-855-355-5777 to find out how to withdraw money.