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Health Insurance in New York

Health insurance plans cover part of the bills for unexpected medical treatments. In New York, health insurance is available to individuals irrespective of national origin through private insurance companies or the health insurance marketplace.

Public health plans in New York may be free or come at a low cost and are ACA compliant. For instance, Medicare, Medicaid, and the Children's Health Program (CHIP) are some health plans through which the government subsidizes healthcare costs. They are available to residents all through the year. New York Medicaid provides health coverage for over 7.3 million low-income earners. Individuals below age 65, children, and low-income pregnant women can register for health insurance by:

  • Visiting the NY State of Health website

  • Using the services of an a health insurance agent or broker, or enrollment assister

  • Calling 1 (855) 355-5777 or 1 (800) 622-1220

In addition to the list above, individuals above 65 years or those living with disabilities can apply for Medicaid through:

New York residents can also purchase private health insurance (Qualified Health Plans) through insurance companies. Private health insurance is available to New Yorkers during the open enrollment period and can be bought on the NY State of Health website or directly from an insurance company.

Irrespective of your health insurance preference, it is best to seek the advice of a New York state-licensed health insurance agent. Licensed health insurance agents are familiar with the New York health marketplace and will help you find the health policy that will meet your insurance needs.

How Does Health Insurance Work in New York?

New York health insurance works similarly to other insurance plans; the insureds get health coverage from insurance companies for health issues that may develop in the future. To enjoy coverage, they must pay a premium when due. Furthermore, depending on the type of health policy, an insured may be required to pay part of the cost of treatment as deductible, copay, and coinsurance based on the agreed amount or percentage.

  • Premium is the cost of the insurance and is usually a monthly payment for insurance coverage.

  • A deductible is an amount the insured has to pay towards health care before the insurance company steps in to pay part of the cost for covered services.

  • Copay is an agreed amount an insured has to pay towards medical treatments, health care services, or drug prescriptions, and it applies to every treatment until the deductible is reached.

  • Coinsurance is the percentage of a medical cost an insured has to pay after spending up to the deductible.

All types of insurance in New York are under the supervision of the New York State Department of Financial Service. Insurance companies providing health insurance in New York must comply with the state insurance laws. In addition to state laws, they must also abide by federal health insurance laws that include:

Although state law does not mandate health insurance for New Yorkers, it requires individual and employer-provided group health insurance to cover certain state-required benefits. There are 12 health insurance companies in New York offering different types of health policies, and these policies include:

  • Managed care services that provide health care treatments for payment. These types of health insurance plans include:

  • Health Maintenance Organization (HMO): This type of health plan restricts members' choices of physicians to a pool of network providers. An insured will choose a primary health care physician, or the insurance company delegates one. An HMO plan will not pay for treatment if an insured uses an out-of-network doctor unless it is an emergency. HMO plans are generally cheaper than other insurance plans.

  • Exclusive Provider Organization (EPO): This is a hybrid form of the HMO plan. An insured is limited to in-network medical care, but unlike HMO, it does not require the use of a primary health care physician.

  • Point of Service (POS): This HMO plan requires the insured to have a referral from a primary health care doctor to consult with a specialist. With a POS plan, the insured pays less for treatment by using in-network doctors.

  • Preferred Provider Organization (PPO): This type of health plan permits an insured to engage the services of out-of-network healthcare providers. However, the insured will pay less for treatment by using an in-network doctor.

  • Traditional Major Health Insurance: This type of health insurance allows the insured to get treatments for serious illnesses from any physician of choice, and the insurance company will pay the bill. Insureds can pay bills for medical treatments and get reimbursed by their insurance companies. Traditional health insurance provides individual or group coverage to citizens and legal residents of the U.S.

  • Limited benefits health plans: These plans attract lower costs than other health insurance plans and offer lower benefits. Limited benefits health plans are more restrictive and pay a predetermined amount for treatments irrespective of the total cost.

New York residents seeking to buy individual or family health insurance plans can do so during the open enrollment period at the health insurance marketplace, typically between November and December. Individuals that could not purchase health plans during the enrollment season can enroll during the Special Enrollment Period (SEP) if they meet the qualifying criteria. Group health plans are available directly from the insurance company (off-exchange) all year round.

In New York, all new individual or small-group insurance plans are ACA-compliant, regardless of whether they are from the marketplace or off-exchange.

Nearly 8% of New Yorkers under the age of 65 (approximately 1 million residents) do not have any form of health coverage. Also, 7.6% of individuals in this same age bracket have disabilities. The percentage of New York adults that are overweight or obese rose from 43% to 63.2% between 1997 and 2019, while 28,200 New York residents die annually from tobacco-related illnesses.

Although health insurance is not compulsory, the state makes it easy for its residents to access health insurance in New York through:

  • The New York Health Insurance Marketplace

  • The Federal Government Health Insurance Marketplace

  • Employers

  • A New York state-licensed health insurance agent

  • Membership in a cooperative association

  • State or federal-funded health insurance programs like Medicare, Medicaid, and Children’s Health Insurance Program (CHIP)

  • Parent’s health insurance plans for children and young adults below 26 years

  • Health insurance plans provided by colleges.

How Does Group Insurance Work in New York?

Group health provides health insurance coverage at a lower cost because the insurer spreads the risk evenly among the group members. However, this type of health insurance in New York has the disadvantage of being terminated once there is a change in the insured’s job situation. In New York, a health insurance group must have at least two people. The Affordable Care Act mandates that employers with more than 50 full-time employees offer health insurance to them and their dependents below 26 years or pay a fine.

How group health insurance works in New York depends on who bears the cost. For instance, with employer-provided group health insurance, the employer may pay all or part of the medical costs of the group members. The types of group health insurance available include:

  • Small group health plan - This type of group health insurance is suitable for employers with less than 50 employees. These ACA compliant plans must comply with any of the four metal level categories. For a small group health plan, the employer pays a part of the premium while the employee pays the deductible, copay, and coinsurance.

  • Fully insured employer group plan - With this type of group health insurance, the employer or association buys the policy from the insurance company and pays part of the premium, while the rest may be deducted from employees' wages. The insurer manages employee claims and benefits in exchange for an annual premium.

  • Self-funded group health plan - With this type of group plan, the employer negotiates directly with the health service providers and pays the medical bills of employees out-of-pocket. With a self-funded group plan, employers save costs on premium payments.

  • Health Maintenance Organization (HMO) - Group members of HMO have access to a network of health service providers that provide medical care at affordable rates. Members of the group use services of providers within the network and will pay out-of-pocket if they use out-of-network service providers.

  • Preferred Provider Organization (PPO) - Unlike the HMO plan, PPO is more flexible and allows the member to choose any physician. However, they will pay less if they use in-network physicians.

  • High-deductible Health Plan (HDHP) - Members of this group make high out-of-pocket payments for deductibles, copays, and coinsurance. The plan compensates for the high deductibles with low premiums.

How Does Individual Health Insurance Work in New York?

An individual health plan is coverage you buy on your own and do not get from an employer or a government-run program. It provides health coverage for individuals and their family members. Individual health insurance in New York is suitable for sole proprietors, self employed, and persons who do not have employer-provided health insurance policies are ineligible for state-run health programs like Medicare, Medicaid, and CHIP.

Individual health insurance is a guaranteed issue and covers the ACA essential health benefit that includes coverage for:

  • Emergency services

  • Pregnancy, maternity, and newborn care

  • Hospitalization (for surgery and overnight stay)

  • Prescription drugs

  • Laboratory services

  • Ambulatory patient services

  • Preventive and wellness services and chronic disease management

  • Rehabilitative and habilitative services

  • Pediatric services

  • Mental illness and substance use disorder services

Individual health insurance covers acute medical treatments and health services like cancer treatments, organ transplants, emergency treatments, hospitalization, and preventive care. It does not cover:

  • Treatments for self-inflicted injuries

  • Cosmetic surgeries

  • Fertility treatments

  • Obesity

  • Alcohol or substance abuse

  • Dental treatments

In New York, individual health insurance is available through the health insurance marketplace during the open enrollment period or special enrollment period. It is also available outside the marketplace. However, buying it through the markets makes policyholders entitled to premium subsidies (premium tax credits) and cost-sharing reductions if they are eligible.

In New York, there is a 90 days grace period for insureds receiving Advanced Premium Tax Credits (APTC) who have paid a premium for at least a month in the benefit year. However, if payment is not made within the grace period, the insurance company may terminate the policy retroactive to 30 days after the insured’s last premium payment. Also, insurers must allow a 10 - 30 days cooling-off period.

What are Alternative Health Plans in New York?

These are health plans that individuals can buy to save on medical costs. They can not be used as major medical plans because, unlike traditional health plans, they do not offer comprehensive health coverage and are not compliant with the Affordable Care Act. Alternative health plans are supplementary health plans that cover gaps in coverage of primary health plans. They:

  • do not provide coverage for all medical issues, and do not cover pre-existing conditions

  • have waiting periods, and the insurers have annual payment limits;

  • do not have to provide access to government subsidies like tax credits and cost-sharing reductions.

In New York, alternative health plans include:

  • Association plans

  • Discount plans

  • Limited benefit plans

  • Subscription plans

NOTE: As of 2022, the State of New York was not permitting the sale of short term health insurance.

LIMITED BENEFIT HEALTH PLANS:

These plans run for a limited duration and provide reduced coverage compared to major health plans in New York. They only cover some of the costs of health care. They are supplemental health plans that act as a backup to traditional health plans. Limited benefit health plans provide additional coverage for individuals seeking to close the coverage gap left by their primary health plans. Due to their limited coverage, limited benefit health plans are less expensive than major health plans.

In New York, limited health plans include:

Fixed indemnity plan

This pays a predetermined amount directly to the health care provider or insured. This policy does not come with a deductible and will pay the agreed amount if an insured event happens. An insured can use this policy to make out-of-pocket payments for deductibles, copays, and coinsurance. The advantages of fixed indemnity plans are:

  • they are low-cost and require few upfront payments

  • payouts are known in advance, and there are no uncertainties about how much the insured is to be paid.

  • they can be bought from insurance companies at convenient times without waiting for the enrollment period as they are not sold in the marketplace

  • they are flexible and can be designed to meet particular needs

Fixed indemnity plans also have downsides, which include:

  • non-coverage of pre-existing conditions

  • Payment of fixed amounts irrespective of the medical costs

  • insufficient coverage

  • lack of coverage for prescription drugs

Accident plans

This plan pays part of the medical bills for bodily injuries from certain types of accidents. It pays for medical treatments for injuries that do not have coverage under primary health insurance or disability insurance. Accident plans include coverage for:

  • Fracture

  • Dismemberment

  • Accidental death

  • Dislocation

  • Laceration

  • Burns

  • Dental injuries

Accident plans can also be used to pay out-of-pocket expenses, including deductibles, copays, coinsurance, lab work, emergency services, and ambulance rides.

In New York, the payout for an accident plan depends on the accident's severity and is made directly to the policyholder, who may decide to use it for other pressing needs. However, there may be restrictions on the frequency of claims. If the insured dies in an accident, the death benefit goes to the beneficiaries.

Disease plans

These disease-specific health insurance coverage policies only become active when the insured is diagnosed with certain illnesses. The coverage for these plans is limited to the illnesses stated in the policy document. Disease plans can serve as a source of income for an insured that is down with a critical illness that limits the ability to earn a living. For instance, cancer insurance will pay benefits to an insured who needs a break while undergoing treatment.

Critical illnesses plan

This plan pays lump-sum cash to the insured if they are diagnosed with terminal illnesses like:

  • Cancer

  • Alzheimer

  • Amyotrophic Lateral Sclerosis (ALS)

  • End Stage Renal Disease (ESRD)

  • Benign Brain Tumor

  • Stroke

  • Major Organ Transplant

  • Heart Attack

  • Coronary Artery Bypass Graft

  • Invasive Cancer

  • Illness-induced coma

SUBSCRIPTION HEALTH PLANS:

Also known as direct care or concierge care plans, they provide health care services to members for monthly, quarterly, or annual payments. These plans suit individuals seeking access to doctors and a wide range of health care services. Members may have to pay additional fees for lab work and other services in New York, and members pay for services that are not part of the benefits out-of-pocket. With subscription plans:

  • Health care services are accessible

  • Members can easily unsubscribe if they are not satisfied with the quality of services

  • Consultation time with health service providers lasts longer than with conventional health plans

Like most online service deliveries, subscription health plans have high risks and safety concerns. Steps should be taken to mitigate fraud, scams, and security breaches. For instance, payments through credit cards should be compliant with industry standards. To lessen the risks, a member should:

  • Use an Address Verification System (AVS) to confirm whether the credit card number matches the one in the credit card company’s database

  • Request Card Verification Value (CVV) when inputting card information to safeguard against fraudsters

  • Use complicated passwords to set up accounts to reduce the possibility of being hacked.

DISCOUNT HEALTH PLANS:

Discount health plans provide health care services to members at a discounted rate for a monthly or annual payment. It is suitable for individuals with low incomes seeking affordable health care. Discount health plans are not types of health insurance but only offer health care at reduced rates and cannot replace major medical plans. A discount health plan is affordable, and the fee may be as low as $8 per month, but it occasionally charges a one-time non-refundable enrollment fee that may be up to $200. Discount health plans can be used by individuals and families that do not have health insurance as a health program to save costs and access healthcare.

In New York, residents can choose a discount plan for:

  • Drug prescription

  • Vision

  • Dental

  • Hearing services

Depending on the required services, discounts for services may range between 5% and 70% of the original costs. The company offering the discount plan provides a list of health care providers that are part of the network, and members must engage only the services of participating doctors. Although discount health plans save costs, have no restriction on who qualifies for coverage, and require no medical examination, they should not be relied on for comprehensive coverage. Before opting for discount plans, note that they may come with issues like:

  • Misinformation on the benefits by the providers

  • Discounts may not be up to what is being advertised

  • False information on participating health care providers

  • Refunds may be less than promised if services are low quality or not rendered

  • Disconnected or non-functional phone lines

  • Costly monthly fees

Members should research before signing up for discount health plans to avoid being scammed.

ASSOCIATION HEALTH PLANS:

These are plans that provide coverage for individuals and small businesses at low rates. In New York, multiple businesses may come together to form a large group for medical benefits to save costs. Association health plans are not health plans; they only act as tools for individuals and small businesses to access health care as a large group and enjoy the benefits of the large health insurance market. Association health plans do not comply with all ACA rules.

Some of the benefits of association health plans (AHPs) include:

  • Exemption from costly ACA requirements, for example:

    • AHPs avoid payment of fees that all individual health plans must pay; for example, AHPs do not pay for risk adjustment

    • They do not pay cost-sharing reduction, which was formerly paid by the government but is now added to the premium

    • They cost less than individual plans because they do not have to provide essential health benefits coverage

  • They are flexible - They can be designed to remove benefits that are not needed to save costs. For instance, a male member will not have to pay for the cost of maternity care, which is a must under individual health insurance.

  • They are an alternative way to access health care - AHPs offer a different option from the traditional ways of accessing the health insurance market and also help lower medical treatment costs.

  • They are compatible with health savings accounts (HSAs), which can be used to pay for medical expenses. However, the AHP must be an HSA-qualified high-deductible health plan to have this benefit.

Association health plans also have limitations, including:

  • Lack of focus on consumer protection

  • They may avoid providing essential health benefits because they are not mandated to cover them

  • They may weaken ACA health plans if there is high patronage.

DIRECT PRIMARY CARE

Direct Primary Care (DPC) is a financial arrangement between a patient and a doctor. It cancels the need for an insurance provider and eliminates claim filing, copays, coinsurance, and premium payment. The patient makes a monthly payment to the health care provider monthly in exchange for medical care. DPC is suitable for individuals that like to:

  • spend more time with the doctors for in-depth consultations

  • know the costs before commencing treatments

  • have easy access to doctors

  • eliminate the cost of health insurance

Some of the disadvantages of DPC are:

  • Monthly dues only cover consultation fees; patients pay for testing, procedures, or medication out-of-pocket.

  • For individuals that combine DPC with HDHP, DPC monthly membership fee does not count as deductible because direct primary care is considered a health plan.

  • Lack of coverage for some health-related issues may lead to exposure to high medical bills.

Typically, most patients that use direct primary care also purchase High Deductible Health Plans (HDHP) to cover the costs of expensive medical treatments. DPC exposes patients to out-of-pocket payments for expensive medical procedures like surgeries, cancer, and heart attacks which the doctor may not be qualified for.

TELEHEALTH and TELEMEDICINE

Telehealth is the use of telecommunication to deliver health care services and disseminate health information at a distance. Telehealth is for individuals who:

  • live in remote communities that may not have access to health care facilities

  • seek knowledge on the methods of preventing infectious diseases like COVID-19, Ebola, and monkeypox, as well as STDs like HIV and many others

  • need access to medical specialists

  • need advice on self-health care management

  • need to educate, or communicate with team members or individuals receiving medical treatments.

  • live in inaccessible communities

  • have limited ability to move due to time or transportation constraints

  • want to be seen by the medical professional fast

Telehealth covers remote health education, consultation, and remote diagnoses of patients, which are done through:

  • Live video: This involves a two-way real-time interaction between the patient and doctor (or health care provider).

  • Mobile health: It involves the use of mobile phones, smartphones, or tablets to access health-related information

  • Store-and-forward: A Patient’s health history and symptoms of illness are sent to doctors through electronic communication for medical evaluation. For instance, a doctor in a distant location may diagnose patients’ illnesses by looking at their medical histories and symptoms.

  • Remote monitoring: This involves transmitting a patient’s medical data to a doctor in a distant location for analysis using electronic communication after the necessary test. For instance, the vitals of an in-patient may be transmitted to a doctor in a different hospital for analysis and drug prescription.

Telehealth covers various health care services, including clinical services, training, meetings, and education.

Telemedicine is a section of telehealth that deals with virtual clinical services: such as:

  • Doctor-patient consultation (doctor’s visit)

  • Patient diagnosis and evaluation

Telehealth and telemedicine help individuals access health services that may be unavailable to them due to location. For instance, people living in remote areas can have a virtual consultation with doctors.

Commercial Health Insurance

These are health plans that private insurance companies provide in New York. Commercial health insurance is a profit-making venture, unlike federal and state-administered plans like Medicare and Medicaid. There are two major categories, group and non-group commercial health plans. In New York, group commercial health insurance offers healthcare services at lower costs than non-group insurance because insurance companies spread medical costs among group members. Also, it is not obligated to offer essential health benefits and is exempted from some of the charges that non-group health insurance pays. Group commercial health insurance plans include:

  • Health Maintenance Organization (HMO)

  • Preferred Provider Organization (PPO)

  • Point-Of-Service (POS)

  • Health Reimbursement Account (HRA)

  • Long Term Care (LTC)

Other examples of group commercial health plans are Medicare Advantage and Medigap plans. The Affordable Care Act requires all businesses with more than 50 employees to offer health insurance to their staff. Although New York does not mandate it, group commercial health insurance is suitable for companies that want to cut down the costs of employees' health insurance. To qualify for group insurance, a business must:

  • have at least one full-time employee (excluding the business owner and spouse) working at least 30 hours weekly

  • be recognized by the state as a business entity

Employers providing group commercial health insurance to their employees and their family members must pay part of the cost of coverage as a cost-sharing arrangement. Based on the nature of the business and the metal level plan, the percentage of the premium paid by the employer may be between 10% and 90%. There are two types of group commercial health insurance; these are:

Small-group health insurance: This is suitable for small businesses with fewer than 100 employees. Small group health insurance complies with the Affordable Care Act, and insurance companies cannot set premiums based on medical history. It must cover the essential health benefits and fit into any of the metal level plans. Without a “dollar limit” on the amount, the insurance company can pay towards treatments.

The benefits of small-group health insurance include:

  • Tax benefits to the business owner (such as tax deductions and credits)
  • Tax benefits to workers (they can pay their portion of the premium pre-tax salary deduction)
  • Healthier employees may lead to increased production and better employee retention.

Large-group health insurance: In New York, it is a group insurance plan that covers businesses with over 100 employees. The law does not mandate businesses to have large-group health insurance. Also, it does not have to cover the essential health benefits.

Speak to a New York-licensed health insurance agent to find out more about getting commercial health insurance for your business.

New York Disability Income Insurance

Disability income insurance is health insurance that provides temporary cash benefits to eligible wage earners incapacitated by injuries or illnesses and unable to carry out activities to earn a living. New York law requires employers to provide disability income insurance to their employees for off-the-job injuries. It also provides weekly cash benefits to an insured if unemployed but eligible for unemployment benefits.

Disability income insurance in New York pays a cash-only benefit that is:

  • 50% of average weekly wages for the previous eight weeks the insured worked

  • Not more than the maximum amount allowed by law ($170 per week)

  • Taxable income (social security and Medicare taxes)

  • Payable for a maximum of 26 weeks of disability (minus days taken for family leave) during a fifty-two consecutive calendar week

There are two types of disability income insurance in New York:

  • Short-term disability income insurance pays a portion of the insured’s regular wages if injured or ill for a short period. The amount paid is usually 75% of the salary. This type of disability insurance typically pays for between three and six months. However, depending on the insurance company, payment may extend up to two years.

  • Long-term disability income insurance applies to individuals who have been incapacitated for several months or years. It covers 60% to 70% of the insured’s salary, depending on the disability income insurance.

According to the Social Security Administration, 1 in 4 adults in the United States will become disabled before reaching 65 years old.

New York Workers’ Compensation Insurance

Workers Compensation Insurance covers workplace-related injuries and injuries occurring anywhere the employee acts on behalf of the business. For instance, it pays the medical or death benefit if a worker sustains injuries or dies in an auto accident while in traffic for a work-related purpose. Furthermore, it provides coverage against mental illness and injuries that may result from violence, terrorism, and natural disasters while working. New York state law requires employers to have workers’ compensation insurance which must meet coverage requirements that are particular to their business types. In New York, Workers’ compensation insurance is available through:

Workers’ Compensation Insurance does not cover:

  • Injuries due to employee’s intoxication

  • Intentional injuries

  • Injuries resulting from fights caused by the employee

  • Pre-existing injuries

  • Non-job related injuries

Workers’ compensation insurance is a standalone plan, not part of the Business Owner Plan (BOP). In New York, the cost depends on:

  • Employer’s industry classification code: This rates industry based on the risks involved. For instance, industries like mining, logging, and trash haulage attract higher premiums than the finance industry because of their high-risk exposures.

  • Location: Exposure to catastrophes, either artificial or natural catastrophes will raise the premium. For example, business locations prone to hurricanes or places that have experienced terror attacks pay higher premiums.

  • Experience rating: Industries with high rates of claims pay high premiums for coverage.

As a worker, the benefit of Workers’ Compensation Insurance depends on the severity of the injuries, the duration, and whether it is a temporary or permanent impairment that leads to a reduction in earnings. Employees can only file claims under this plan in New York. However, coverage in other states can be activated by listing the states where the employee may be working from time to time under the “other states” section of the policy document.

How Does Health Insurance for Seniors Work in New York?

Senior citizens’ health insurance providers cover the medical costs of individuals aged 60 years and above. These plans include Medicare, Medicaid, Medicare Advantage, Medigap, and Long-term Care Insurance. Data from the U.S Census Bureau estimate that in 2020, 16.9% (3.4 million people) of the New York population are above 65 years and may be eligible for the senior health insurance program. The New York State Department of Health usually runs state health insurance programs (SHIP) counseling services to educate beneficiaries and their caregivers.

SENIOR HEALTH INSURANCE USAGE

in the

STATE of NEW YORK

Original Medicare 52%
Medicare Advantage 48%
Original Medicare Part A and Part B 43%
Medicare Advantage and Other Health Plan Part A and Part B Beneficiaries 48%
Medicare Part D (Medigap) 37%
Medicare Advantage Prescription Drug Plan 44%
Source: Data.CMS.gov, 2022

MEDICARE

Medicare is a federal health insurance program that provides health care at a subsidized rate. This plan protects citizens that are 65 years and above or younger individuals that meet certain eligibility criteria. In New York, it provides free preventive services for nearly 3.7 million residents receiving services from doctors and other health care service providers participating in the Medicare program. To have Medicare coverage, an individual must apply for consideration. In addition, an applicant in New York must:

  • be 65 years or older, or will be 65 years in the next three months

  • have Chronic Renal Failure or Amyotrophic Lateral Sclerosis (ALS)

  • have income at or below 120% of the federal poverty level based on household size

  • have worked or paid Medicare taxes for at least ten years

Medicare has four parts: Part A, Part B, Part C, and Part D.

  • Medicare Part A & B (original Medicare) covers hospital and medical insurance. Part A provides inpatient coverage, while Part B covers outpatient care, certain doctor’s services, preventive services, and certain medical supplies.

  • Medicare Part C (Medicare Advantage) supplements the original Medicare plans. It is a combination of the Original Medicare plan with a few additions depending on the plan type. To have medicare advantage coverage, an individual must apply to be considered. Unlike Medicare Part A & B, it is not an insurance program that pays a fraction of certain health care costs. Medicare Part C covers services that are part of Original Medicare, which include:

    • Hospital stay

    • Doctor’s visits and health care services

    • Preventive care services like screening and medical examinations

    • Lab tests

    • Part A benefits excluding hospice

    • All part benefits

    • Outpatient treatments

  • Medicare Part D (Prescription Drugs) covers outpatient prescription drugs, including a certain class of prescription drugs like those for cancer and HIV treatments. In New York, it is available through private insurers, and though it comes with a deductible and copay, it benefits individuals with an Original Medicare plan. In 2022 the average Medicare Part D plan was $33, which was a 4.9% increase from the 2021 levels.

Medicare Part D does not cover drugs that are:

  • For cosmetic purposes or hair growth

  • For weight loss or gain

  • Over-the-counter drugs

  • For treating sexual dysfunction

  • For fertility

  • Covered under Medicaid Part A or Part B.

MEDICAID

Medicaid is a federally funded health insurance program that provides coverage to millions of low-income U.S citizens. The federal and state governments fund the program. With an approximate population of 20 million people in the state, in 2021 New York Medicaid program provided health care coverage to over 57% of the state’s residents under the age of 65, who qualified for coverage as low-income earners.

Medicaid provides a wide range of healthcare services through a large network of healthcare providers. Beneficiaries can access health care services through Medicaid cards or managed care plans (for those enrolled in managed care). Certain Medicaid services have copays (these can be waived if the beneficiary cannot pay).

To qualify for Medicaid coverage in New York, an individual must be a legal U.S. citizen or a lawful permanent resident, plus a. resident of the State of New York with an income below 133% of the Federal Poverty Level. It is available to children, pregnant women, single persons, families, and persons certified blind or disabled. The resource and income level for Medicaid eligibility changes on January 1 of each year, and only individuals that are certified disabled or above 65 years are eligible for the resource test. Eligibility for New York Medicaid may depend on medical eligibility, marital status, and income level. Families not eligible for Medicare may enroll in Child Health Plus and Family Health Plus.

Medicaid coverage includes:

  • Emergency care

  • Doctor’s visits

  • Medical equipment and appliances

  • Regular medical checkups and follow-ups

  • Immunization

  • Medicine

  • Dental care

  • Nursing home care

  • Hospital stays

  • Emergency ambulance services

  • Medical supplies

  • Eyecare and eyeglasses

  • Lab tests and x-rays

For women with incomes higher than the eligibility income, Medicaid coverage may be limited to perinatal care. Eligible individuals may apply for Medicaid through:

  • The New York State of Health, where Enrollment Assistors offer personalized help. They can also speak with the marketplace customer care service center by calling (855) 355-5777

  • Managed Care Organization (MCO)

  • Medicaid Helpline (800) 541-2831

  • Local Department of Social Services

Information on the New York Medicaid program can be accessed on the New York Medicaid website, by calling the New York State Health Department Growing Up Healthy Hotline at 1 (800) 522-5006, or through the local county department of social services.

MEDIGAP

Private insurance companies sell Medigap insurance (Medicare Supplement) to supplement or cover the costs of health care that do not have coverage under Medicare Part A and B. All Medicare beneficiaries in New York are eligible for Medigap. In New York, insurance companies must sell Medigap at all times to Medicare beneficiaries irrespective of age (above or below 65 years), and health status must not be a determining factor. In New York, there are up to twelve different Medigap policies. In 2022, approximately 1.4 million New York residents had Medigap coverage.

When choosing a Medigap plan:

  • Note that it is only available to individuals with Original Medicare and other eligibility criteria.

  • Individuals aged 65 years and above are eligible to buy Medigap without restriction.

  • Compare policies across different insurers, standardized policies, and those with similar names should offer the benefits.

  • For individuals seeking coverage for certain medical conditions, ensure coverage is not excluded. Medigap can exclude coverage for some medical conditions for a limited period.

  • Compare prices across different insurers; although benefits are standardized, the premiums are not.

  • Contact a New York state-licensed health insurance agent and ask questions that will help to explain the terms and conditions of Medigap insurance.

LONG-TERM CARE (LTC) INSURANCE

This is an insurance plan that covers part or all of the costs of assisted living for individuals aged 65 years and above. In New York, Long-Term Care is available through private insurance companies and pays for custodial care for individuals who can not perform activities of daily living (ADL) due to long-term illnesses or injuries. LTC is for individuals who due to illness or disability, need assistance to perform activities like bathing, feeding, dressing, using the toilet, moving around, and short-term or long-term memory loss.

To find out more details about senior health insurance in New York, contact a state-licensed health insurance agent who specializes in health care for elders.

What are Additional or Stand-Alone Health Insurance Options in New York?

These are supplemental plans in New York that offer coverage in addition to those provided by an individual’s primary health insurance. They cover health care costs that are not part of the benefits of a primary healthcare plan. Typically, these plans are bought as stand-alone policies from private insurers.

Additional health insurance plans in New York include but are not limited to:

  • Dental Insurance

  • Vision Insurance

  • Hospital Indemnity Insurance

  • Critical Illness Insurance

  • Accident Insurance

  • Disability Insurance

  • Long-Term Care Insurance

  • Medigap

In New York, many health insurance options are available, and the choice depends on the type of coverage an individual seeks. For instance, individuals seeking coverage for illnesses like cancer, heart surgery, stroke, or kidney diseases may opt for critical illnesses insurance. Always discuss your insurance needs with a state-licensed insurance agent who can assess your needs and guide you through the process of selecting the appropriate coverages, while optimizing the savings through discounts.

What Health Insurance Rights Do I Have in New York?

As a health insurance consumer in New York, you have the following rights:

  • Access to information about your health insurance

  • Your insurer must provide information on the cost of using an out-of-network health care provider if you are using an in-network service provider when demanded

  • Hospitals must not hide information on the fee for treatment if they do not belong to your in-network

  • Your health plan must provide you access to healthcare when needed

  • In emergencies, your medical fees should not go beyond the In-network deductible, copay, and coinsurance

  • The law protects you from surprise medical bills

  • If you are denied coverage, your health plan must have a grievance and utilization review process for appeal

If you feel your right as a health insurance consumer in New York has been violated, you can file a complaint online or download a complaint form through the New York Department of Financial Services website.