ABCs of Health Care Reform

Frequently Asked Questions

+ Eligibility

See if you and your family qualify for New York health insurance.

Who qualifies for individual commercial health insurance in New York State?
You can apply for coverage through the NY State of Health Marketplace or through a New York insurer offering coverage in your county if you are:

  • New York State resident
  • Legal U.S. resident or lawfully present immigrant
  • Not eligible for affordable, adequate health insurance from your employer. Ask your health benefits administrator at work.
  • Ineligible for other types of health insurance (such as Medicaid, Medicare or employer-sponsored insurance) that meets the government standards for the types of coverage you need to avoid a tax penalty

Can I get health insurance for my spouse or domestic partner and my kids on and off the NY State of Health Marketplace?
Yes, you can get health insurance for you, your spouse or domestic partner, your kids or any other eligible family member. If your child needs insurance but you don't, you can get coverage just for your kids.

I'm not a legal U.S. resident. Can I apply for health insurance?
Lawfully present immigrants can apply for health insurance on the NY State of Health Marketplace. Children of unlawfully present immigrants may be able to get coverage through Child Health Plus, a low-cost plan for young people up to age 19.

Who's eligible for the Essential Plan?
Adult individuals (but not families) who qualify based on income and other factors are eligible for the Essential Plan, a plan with a $0 or $20 premium. You must be a New York State resident age 19 to 64 (legal U.S. residents) or age 21 to 64 (lawfully present immigrants). Eligible spouses, domestic partners and children must enroll in the Essential Plan separately, under their own individual policy. See if you qualify.

Does my eligibility change if I become pregnant or need long-term care?
If you're enrolled in a metal plan (Platinum, Gold, Silver or Bronze), then pregnancy and long-term care are covered. If you're enrolled in the Essential Plan and need this care, you will need to change plans, at no extra cost. For help with this, contact the NY State of Health Marketplace at 1-855-355-5777, Monday to Friday, from 8 am to 8 pm, or Saturday, 9 am to 1 pm.

+ Signing Up

Get the facts on enrolling in health care coverage, including where, when and how.

I'm ready to apply? What next?
First, it's important to know what you're eligible for so you get the best deal. Use our Affordable Care Advisor to check your eligibility, estimate costs and start enrolling.

Where can I enroll?
You can enroll in our Qualified Health plans both from the NY State of Health Marketplace (required if you want to access financial help) and directly from our website. You must enroll through the Marketplace if you're signing up for our Essential Plan. If you're looking to enroll or reenroll in Medicaid or Child Health Plus, call us at 1-800-233-1831, daily from 8 am to 8 pm, and we'll help you sign up.

What's the NY State of Health Marketplace?
The NY State of Health Marketplace is New York State's health insurance exchange. It offers qualifying individuals lower-cost coverage from private health insurers. You can purchase plans here even if you don't qualify for financial assistance. Depending on your eligibility, you can choose from "metal plans" (Platinum, Gold, Silver and Bronze), catastrophic plans, $0 or $20 Essential Plan, Medicaid and Child Health Plus.

When can I enroll?
You can enroll in our Qualified Health plans during an annual open enrollment period lasting from fall to winter (dates may differ each year). You can enroll in the Essential Plan, Medicaid and Child Health Plus at any time of the year. You may also be eligible to enroll in the Qualified Health plans outside open enrollment if you experience a qualifying event.

What information do I need to sign up for an individual commercial health plan?
You need the following information, but not the actual documents. It's still a good idea to have these documents with you when you enroll so you can easily find the needed information:

  • Birth date
  • Social security number
  • Document numbers for lawfully present immigrants (e.g., Green Card or Naturalization number)
  • Employer information (e.g., pay stubs, W-2 forms, 1099 forms)
  • Policy number for any health plan you or your family may already have
  • Any ideas for health plans you may want
  • Email address if you're enrolling online

Can I get help filling out my application?
Yes, call us at 1-800-233-1831 for help by phone or to set an in-person meeting with one of our Marketplace Facilitated Enrollers. You can also get help from a Navigator or broker/agent through the NY State of Health Marketplace (from the link above, choose EmblemHealth from the "Issuer Affiliations" drop-down menu to work with someone familiar with our plans).

+ Health Plans

Learn the basics about the EmblemHealth plans available to individuals and families.

What types of individual health plans does EmblemHealth offer?
EmblemHealth offers New Yorkers a wide range of plan choices, as described below. Your eligibility may depend on certain factors, such as income, age, and the county you live in.

  • Both Standard and Nonstandard plans: Standard plans are those whose benefits and out-of-pocket costs are defined by New York State and are the same across insurers offering these plans in the State. Nonstandard plans are those whose benefits and out-of-pocket costs are defined by the health insurer offering the plans and are unique to that insurer.

  • Both on and off the Marketplace: We offer four types of standard metal plans, two nonstandard metal plans (EmblemHealth Silver Value and EmblemHealth Bronze Value), a catastrophic option (EmblemHealth Basic), and dental and vision plans for adults and kids. These plans offer the same benefits both on and off the Marketplace. Review our plans.

  • On the Marketplace only: We offer the Essential Plan (lower-cost plan for individuals only), Medicaid ($0 premium) and Child Health Plus (lower-cost plan for young people under age 19).

  • Off the Marketplace only: We offer Medicare Advantage for individuals age 65 and older, and individuals younger than 65 with certain disabilities.

What's the difference between the metal plans?
All the standard metal plans (Platinum, Gold, Silver and Bronze) and the catastrophic option offer the same medical benefits, but with different cost-sharing (deductible, copays and coinsurance). In general, the higher your premium (monthly plan cost), the lower your cost-sharing — and vice versa.

  • Visit the doctor often? You may want to choose a plan that costs more per month (like Platinum or Gold), but has lower out-of-pocket costs.

  • Don't see the doctor often? You might choose a plan that costs less per month (like Silver or Bronze), but has higher out-of-pocket costs.

What's the difference between the EmblemHealth "metal" plans and the Essential Plan?
Qualified Health and Essential Plans have similar health benefits, but different ways of providing financial assistance. With the Qualified Health metal plans (Platinum, Gold, Silver and Bronze) you may be eligible for tax credits to lower your monthly premium or cost-sharing subsidies to lower your out-of-pocket costs (deductible, copay and coinsurance). With the Essential Plan, the cost savings are built in, through a $0 or $20 premium, no deductible, and copays as low as $0.

Which doctors are in EmblemHealth's network?
Our Qualified Health plans use our Select Care and Prime network, and our Essential Plan uses our Enhanced Care Prime network. All three networks include thousands of experienced primary care physicians and specialists, plus facilities and leading hospitals. This includes AdvantageCare Physicians, a multispecialty physician group practice providing team-based care at 35 locations throughout NYC and Long Island.

Use our Find a Doctor tool to check for doctors that participate in the plan you have or are interested in. It's also a good idea to call doctors to confirm they participate.

+ Costs

Find out what costs may apply to your individual or family health plan.

How can I find out if I'm eligible for financial assistance toward health insurance?
Use our Affordable Care Advisor to check your eligibility, estimate costs and start enrolling.

What costs will I need to pay for my health insurance?
There are two main costs: premium (monthly plan cost) and out-of-pocket costs (deductible, copay and coinsurance). The actual dollar amount you'll pay depends on which plan you choose, whether you qualify for financial assistance and whether you get care from network providers.

What's a premium?
It's the monthly cost of a health plan. Premiums are paid each month whether or not you use your benefits.

What out-of-pocket costs can I expect to pay for my health care?
Your plan may include cost-sharing, which is the share of the costs you pay to use your benefits. There are three main forms, which may or may not apply depending on the plan you choose:

  • Deductible: The amount an insured person may need to pay each calendar year before the health insurer starts paying for covered health services. Under our Qualified Health or Essential Plans, some benefits, like certain preventive care services and telehealth, aren't subject to the deductible. This means you won't need to pay into your deductible before using those benefits.

  • Copay: A fixed amount an insured person may need to pay to see the doctor or get prescription medicine.

  • Coinsurance: The percentage of the allowed cost of services you may need to pay toward a covered health service, usually after meeting the deductible, if one applies. (The allowed amount is the cost we and your doctors have agreed to.) Here's how coinsurance works: Let's say your doctor charges $100 for a service, and we've agreed to pay the doctor $50. If you owe 50% of this allowed amount, you'd pay $25.

What's the penalty for not having health insurance?
The penalty is a dollar amount removed from your tax return when you file your taxes. It applies to each month you didn't have insurance over a calendar year. As of 2016, the penalty is $695 per adult and $347.50 per child OR 2.5% of your taxable household income, whichever is greater. After 2016, penalties increase each year as the cost of living or minimum wage goes up.