QUALIFIED HEALTH PLAN

For permission to reproduce all or part of this material contact the New York City Human Resources Administration.

Afnity Health Plan 1(866) 247-5678

EmblemHealth 1 (866) 838-9144

Empire BCBS 1 (866) 478-0376

Fidelis Care New York 1(888) 343-3547

Healthrst PHSP, Inc. 1 (888) 250-2220

MetroPlus Health Plan 1 (855) 809-4073

CareConnect 1(855) 706-7545

Oscar 1(855) 672-2788

United Healthcare 1 (800) 444-8990

Wellcare 1 (855) 582-6172

For more information about a plan:

For more information, please visit NYC Health Insurance Link

at www.nyc.gov/hilink

For information and questions regarding your health

insurance coverage through the Marketplace,

call 1(855) 355-5777

Bill de Blasio

Steven Banks

choosing a

QUALIFIED

HEALTH

PLAN

Helpful tips for selecting a plan through

the NY State of Health marketplace

BRC-959 (E)

Rev. 04/16

Delivery of Care

Each plan will have a different provider network. You can save on health

care costs by getting services only from providers in your plan’s network.

Some plans may require you to choose a doctor to be your Primary Care

Provider (PCP).

• Ask doctors you regularly see for the names of plans sold in

the NY State of Health that they accept.

• Look at the plan’s network to see if it has doctors, hospitals, and

clinics near where you live or work.

• Consider the type of plan. HMO and EPO plans only pay for care

provided by in-network doctors.

• Review the state’s consumer guide to health insurance to find out

how insurers compare on quality of care, complaints received, and

appeals and grievances. Information on new insurers is not currently

available but will be included in future guides. To access the current

guide, visit: www.dfs.ny.gov/consumer/hgintro.htm

Cost

All plans have two types of costs: the monthly cost that you pay up front

(premium) and the cost you pay when you get services (out-of-pocket

costs). Out-of-pocket costs include things like deductibles, copays and

coinsurance. Make sure to look at both types of cost when you consider

which plan is affordable for you.

• Think about how much you can afford to pay each month for coverage.

• Think about how often you will need health care services and how

much you will have to pay for these services. Does the plan have a

deductible (the amount you will have to pay before the plan pays for

services)? What are the copays (the set amounts you will have to pay

for services like a doctor’s visit)?

Plan categories (metal levels)

All plans are divided into four cost-sharing levels, called metal

levels. The metal levels describe how the cost of care is usually split

between you and the health plan. This includes the premium and

out-of-pocket costs.

PLATINUM: You pay 10% / Plan pays 90%

GOLD: You pay 20% / Plan pays 80%

SILVER: You pay 30% / Plan pays 70%

BRONZE: You pay 40% / Plan pays 60%

Each plan charges a different premium for the coverage it offers.

Usually, the higher the premium, the lower your out-of-pocket costs

will be. Platinum plans have the highest premiums and the lowest

out-of-pocket costs. Bronze plans will have the lowest premiums

and the highest out-of-pocket costs. All plans limit the total amount

of your cost-sharing each year (your “out-of-pocket maximum”).

You may be eligible for nancial help to lower your monthly

premium cost and/or your out-of-pocket costs. If you are eligible for

cost-sharing reductions (lower out-of-pocket costs) and enroll in a

Silver plan, you will pay less for your care.

Young adults (under 30 years old) and people who cannot nd

affordable coverage may enroll in a Catastrophic plan. Catastrophic

health insurance plans have low monthly premiums and a very high

deductible.

Paying the Premium

You must pay your rst premium within 10 days of receiving

your bill. Your coverage will end if you do not pay your monthly

premiums.

You can shop for a health insurance plan on the NY State of

Health, the Ofcial Health Plan Marketplace. Private health

insurance plans pay for a portion of the care and services

you receive. They contract with a group (network) of doctors,

clinics, hospitals and pharmacies to provide this care at

agreed upon prices. It’s important to choose the health

insurance plan that’s right for you.

You may also be eligible for subsidies that reduce the cost of

your plan.

PICKING A PLAN

Insurers are limited in how they can make their plans different.

Qualied Health Plans can differ in three main ways:

Services Covered (benets)

Delivery of Care (such as provider network)

Cost (including monthly premiums and how much

you have to pay when you get care)

Services Covered

All plans cover the same 10 benets, including hospital care, prescription

drugs, and doctor visits. Some insurers offer “non-standard” plans,

which have additional benets or substitute certain services for others.

• Check to see if the plan covers your medications on its preferred

drug list.

• Do you want benets beyond the 10 benets offered by all plans?

Examples include dental care and acupuncture. If you do, you can

check to see which non-standard plans offer the benets you need.

You can also consider plans that offer only dental coverage.