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Healthy New York is a plan created by New York State to help low income families. This plan is available to individuals, sole proprietors, and small groups. There are different requirements for each, please be sure the check the proper qualifications below.
There are income guidelines for this plan. The 2008 Income guidelines are as follows:
- Your business must be located in NY state and have 1-50 employees.
- 30% of your employees must have earned wages of $38,000 or less.
- The business MUST NOT have provided group health insurance coverage to its employees within the last 12 months. [A small employer is considered to have provided health insurance, if the employer has BOTH arranged for AND contributed, more than $75 per employee, per month, toward their health insurance.]
- If an eligible employer opts to enroll the business in Healthy NY, the employer must assure:
That 50% of the eligible employees will participate in the program, and at least one participant earns annual wages of $38,000 or less. (A small employer may count employees who have health insurance coverage through another source, such as a spouse or another government program, toward the 50% participation requirement).
The employer will contribute at least 50% of the premium.
- And the employer will offer Healthy NY to ALL EMPLOYEES who are working 20 or more hours a week, and earning less that $38,000. (Please note: Earnings amount is adjusted annually for inflation
There are several plan options to choose from. You can select a standard HMO plan, with prescription coverage or without prescription coverage.
The 2008 Empire HealthChoice HMO Healthy NY monthly premiums for Suffolk County are:
|
w/ prescriptions |
w/out prescriptions |
Individual |
263.86 |
232.61 |
Husband & Wife |
527.72 |
465.22 |
Parent & Child(ren) |
474.95 |
418.70 |
Family |
791.58 |
697.83 |
The Healthy NY benefit packages, which are streamlined, consist of health benefits that cover essential health needs including: inpatient and outpatient hospital services, physician services, maternity care, preventive health services, diagnostic and x-ray services, and emergency services. Applicants may choose a benefit package with or without a limited prescription benefit.
Keep in Mind…
- Even though Healthy NY benefit packages are the same, the health plans may charge different premium rates.
- Once you have chosen which type of benefit package you want - with or without the prescription drug benefit - you will not be able to change your choice of benefit package until your annual recertification or if your premium rate changes.
- Covered services are subject to a copayment. All benefits are provided "in-network" only, except for emergency services or where care is not available through a health care plan’s providers. Otherwise, you must use a health care plan’s network of providers.
- Diagnostic screening for prostate cancer for men
- Coverage for home health care for up to 40 post-hospital or post-surgical visits in a calendar year
- Coverage for 30 post-hospital or post-surgical visits per calendar year for physical therapy
- Inpatient hospital services consisting of daily room and board, general nursing care, special diets and miscellaneous hospital services and supplies
- Outpatient hospital services consisting of diagnostic and treatment services
- Physician services consisting of diagnostic and treatment services, consultant and referral services, surgical services (including breast reconstruction surgery after a mastectomy), anesthesia services, second surgical opinion, and a second opinion for cancer treatment
- Outpatient surgical facility charges related to a covered surgical procedure
- Pre-admission testing
- Maternity care
- Adult preventive services consisting of mammography screening, cervical cytology screening, periodic physical examinations no more than once every three years, and adult immunizations
- Preventive and primary health care services for dependent children including routine well-child visits and necessary immunizations
- Equipment, supplies and self-management education for the treatment of diabetes
- Diagnostic x-ray and laboratory services
- Emergency services
- Therapeutic services consisting of radiological services, chemotherapy and hemodialysis
- Blood and blood products furnished in connection with surgery or inpatient hospital services
If the prescription drug benefit is selected:
- Prescription drugs obtained at a participating pharmacy ($3,000 maximum per person, per year)
Copayments and Deductibles:
Covered services are subject to a copayment. The copayment is an amount that you must pay at the time you receive services. Copayment amounts are the same for each health plan.
If you choose the benefit that includes prescription drug coverage, there is a $100 annual deductible for prescription drugs. This deductible amount is the same for each health plan.
If you enroll in the Healthy NY High Deductible Health Plan Option, any money that you spend on copayments for preventive services cannot be applied towards your plan deductible.
The applicable copayments are:
| Services |
Copayments |
Inpatient hospital services |
$500 copay |
Surgical services |
20% or $200 copay |
Outpatient surgical facility |
$75 copay |
Emergency services (waived if admitted to the hospital) |
$50 copay |
Prenatal services |
$10 copay |
Well-child visits/ Immunizations |
$0 |
All other services |
$20 copay |
Optional prescription drug benefit |
Maximum benefit of $3,000 per individual per year; $100 deductible per calendar year; generic drugs have a $10 copay; brand name drugs have a $20 copay plus the difference in cost between the brand name drug and generic equivalent |
Because Healthy NY has a streamlined benefit package, certain services are not covered. Examples of those services include:
- 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
Coverage under the Healthy NY program is subject to a pre-existing condition waiting period. This means that if the applicant has a medical condition that they have been either diagnosed with or treated for in the last six months, services for the treatment of that condition may be excluded from coverage for up to a year.
However:
- If an applicant has had prior health insurance coverage and has not had a break in coverage that is longer than 63 days, the pre-existing condition limitation waiting period will be reduced or waived.
- Coverage for other services will still be available for all other covered conditions.
Pregnancy is a pre-existing condition in individual contracts. It is not a pre-existing condition in contracts issued to sole proprietors or small employers.
Applicants should check with their health plan in advance to determine how this waiting period would impact the initial coverage of any existing health conditions they may have.
Family Health Plus
Child Health Plus
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