UPDATE!

Bad News: As of January 1, 2012, Healthy NY enrollment is now limited to the High Deductible Health Plan (HDHP). New enrollees can no longer enroll in the standard plan. The HDHP has a deductible of $1,200 for an individual, $2,400 for a family.

Good News: An optional prescription drug benefit is still available and due to federal health care reform, there is no longer an annual limit. There is also no longer a separate prescription drug deductible because all new enrollees get the HDHP.

The above information courtesy of Eric Hausman of National Government Services, for NYC HIICAP.

Overview

Healthy NY is a reduced cost health insurance program available to uninsured workers whose monthly income is above the limits for Medicaid and Family Health Plus. See N.Y. Ins. L. § 4326; 11 N.Y.C.R.R. § 362-1.1, et seq. The program is offered throughout the state through HMOs. HMOs are required to offer the same benefit package without any additions or subtractions. However the HMOs are allowed to charge different premiums. Therefore, it is necessary to shop and compare between the different insurers. To find out which HMOs are available in a particular area and their premium rates, call toll free at 1-866-HEALTHY NY (1-866-432-5849) or visit the Healthy New York website at http://healthyny.com.

Who is Eligible for Healthy NY?

Working uninsured individuals who meet the following eligibility requirements:

1. Health Insurance. Employer does not currently provide applicant with health insurance and has not provided group health insurance during the twelve-month period preceding application.
2. Medicare. Applicant must be ineligible for Medicare.
3. Residency. Applicants must be New York State residents.
4. Employment. Applicants must be employed on a full-time, part-time or episodic basis.
5. Income. Gross household income level is at or below 250% of the gross federal poverty level.

The HealthNY website contains a screening tool to help you figure out if you are eligible for HealthyNY.

What Does Healthy NY Cover?

Healthy NY covers essential health needs including inpatient and outpatient hospital services, physician services, maternity care, preventive health services, diagnostic and x-ray services, emergency services, and a limited prescription benefit. Many services are not covered. The following services are not covered - Mental health services, including treatment and medication for ADHD, depression, and anxiety; Alcohol and substance abuse treatment; Chiropractic coverage; Hospice care; Ambulance, dental care, vision care, durable medical equipment

Covered services are subject to a co-payment. All care is provided "in-network" only, except for emergency services or where care is not available through a health care plan’s providers. Otherwise, the health care plan’s network of providers must be used. Unlike Medicaid, CHPlus A and B, and FHPlus, coverage pursuant to the Healthy NY program is provided subject to a pre-existing condition waiting period. Applicants who have been uninsured for more than 63 days should check with the individual health plans to find out how long the waiting period is for coverage of pre-existing conditions. See N.Y. Ins. L. §§ 4318, 3232.

Co-payments and Deductibles for Covered Services

There is significant cost sharing for enrollees in this program. Covered services are subject to a co-payment at the time services are received. Additionally, for prescription drugs there is an annual deductible.

The amounts of the co-payments and deductible are the same for each health plan. The applicable co-payments are *:

• Inpatient hospital services: $500 co-pay.
• Surgical services: 20% or $200 co-pay.
• Outpatient surgical facility: $75 co-pay.
• Emergency services: $50 co-pay, waived if admitted to the hospital.
• Prescription drugs: Maximum benefit of $3,000 per individual per year; $100 deductible per calendar year; generic drugs have a $10 co-pay; brand name drugs have a $20 co-pay plus the difference in cost between the brand name drug and generic equivalent.
• Prenatal services: $10 co-pay
• All other services: $20 co-pay

*There are no co-payments for routine well-child visits and necessary immunizations.

How to Apply for Healthy NY

Applicants for Healthy NY coverage apply directly to a health plan. All HMOs licensed in New York State are required to offer Healthy NY coverage; other insurers may choose to offer it. Application forms are provided by participating insurers. The HealthyNY website contains a list of participating HMOs and premium rates by county. In addition to filling out an application, applicants will have to provide documentation of their residence, household income, and employment status.

This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.