The great news is that insurance through NY State of Health is for just about anybody who doesn’t have insurance or who is underinsured. This includes people who:

• Live in New York State
• Are not eligible for Medicare
• Are U.S. citizens or legal residents
• Are uninsured or underinsured. People are considered underinsured if their insurance plan does not cover the health benefits outlined by the Affordable Care Act, or if they spend more than 9.5% of their yearly income on premiums for healthcare coverage provided by their employer.
• Currently buy insurance on their own

All documented immigrants, even those who have been in the United States for less than five years, can buy insurance through NY State of Health. Additionally, undocumented parents can apply for health insurance for their child or children. Contact us for more information.

We have plans for all ages, needs, and income levels. To see which Healthfirst plans are right for you, please contact us.

If you’ve had a major life-changing event, called a Qualifying Life Event (QLE), you may be eligible for a new or different health plan. These kinds of events can include birth or adoption, pregnancy, marriage, divorce, a new job, a raise or change in hours, or job loss. When you have an event like this, you’ll be able to see if you qualify for different health plans or to get help paying for your health plan. If you need help at any time, you can contact us and we can help you pick a plan that is right for you.

Yes, parents will be able to choose the best plan for their children. Depending on eligibility, parents can enroll their children in:

• A Healthfirst Leaf or Leaf Premier family plan
• A child-only Healthfirst Leaf Plan
• A Child Health Plus plan
• Medicaid

Contact us to find that plan that’s right for your child.

The easiest way to enroll in a Healthfirst plan is to contact us. Our sales reps can guide you to the best plan for you and ease the enrollment process.

Here’s what you need to apply for a Healthfirst insurance plan:

• Proof of age, such as your birth certificate
• Proof of United States citizenship or legal resident status
• Proof of current income (e.g., pay stubs if you’re working)
• Proof of income, from any of the following:
  • Social Security
  • Supplemental Security Income (SSI)
  • Veterans’ Benefits (VA)
  • Retirement
• Health insurance benefit card or the policy (if you have any other health insurance)
• Proof of where you live
  • Rent receipt
  • Mortgage statement
  • Mail with your address on it

You can sign up for health insurance coverage during Open Enrollment. Please note that certain plans have specific enrollment periods to sign up or switch plans.

However, you can enroll outside the Open Enrollment Period if you’ve had a Qualifying Life Event (QLE). These include:

• A change in family size (birth or adoption)
• Marital status change (marriage, annulment, legal separation, divorce, death of a spouse)
• Job loss or change
• Losing your insurance or more

Need help signing up for a health insurance plan? Contact us for more information.

• For any plan with a premium, your Member ID card will be mailed after the initial payment (known as a binder payment) has been made
• For any plan without a premium, your Member ID card will be mailed upon enrollment
• You can also print a temporary Member ID card from your secure Healthfirst account

Healthfirst has a large network that includes thousands of doctors and specialists. Visit HFDocFinder to find an in-network Healthfirst provider.

Finding a new participating pharmacy is easy. You can:

• Use our Find a Pharmacy search tool to locate one near you
• Call the Healthfirst Member Services phone number on the back of your Member ID card. We’ll help you check if your pharmacy is in our plan network.
• Stop by a Healthfirst Community Office and let us help you look up the participating pharmacies in your community

Pharmacy benefits are different for each Healthfirst health insurance plan. Please check your plan’s formulary for more information on which pharmacy medicines and other items are covered.

Healthfirst has partnered with CVS Caremark to bring you a personal prescription drug account that will give you 24/7 access to important drug benefit information and tools that will make getting your prescription drugs easier. Click here to create your account or log in.

Healthfirst has a large network that includes thousands of doctors and specialists. Visit HFDocFinder to find a participating Healthfirst doctor or hospital and use our Find a Pharmacy tool to locate a pharmacy near you.

You can choose a new Primary Care Provider (PCP) at any time. To make the change, you can log into your secure Healthfirst account* or call us.

*Please note: To create a secure online account, you must be a member of a Healthfirst health insurance plan.

Some of our plans share a provider network, but not all of them do. To make sure your doctor is in-network, please visit HFDocFinder.

If your doctor leaves Healthfirst, we’ll let you know within 15 days of the doctor informing us. We can then help you find a new Primary Care Provider (PCP). There are some circumstances where you may be able to keep your PCP. These include:

• If you’re more than three months pregnant, or if you’re receiving ongoing treatment for a health condition, Healthfirst may cover that doctor’s costs for a short time
• If you’re pregnant, you may continue to see your doctor for up to 60 days after your baby is born
• If you’re seeing a doctor for an ongoing condition, you may continue seeing him or her for up to 90 days.† You’ll then need to see a Healthfirst doctor for treatment. Please talk to your current doctor about the best way to change to a Healthfirst doctor.

If any of these conditions apply to you, or if you have other questions, check with your PCP or contact us. We’re here to help.

^†Your current PCP must agree to work with Healthfirst during this 90-day period.

Depending on the Healthfirst plan you have, you may be eligible to receive free transportation to and from medical appointments and select non-medical appointments. Please refer to your Member Handbook or call the Member Services phone number on your Member ID card for details.

View this fact sheet to learn about your healthcare costs during pregnancy and the postpartum period. For Healthfirst members enrolled in an Essential Plan, or in a Leaf or Leaf Premier Plan (Qualified Health Plan).

If you need coverage outside our network and/or service area, please confirm your plan’s service area in your summary of benefits. Such coverage will be treated as an out-of-network service, meaning you will be responsible for the full cost.

In certain instances, you can petition to receive out-of-network coverage at in-network prices, but this approval must be obtained before receiving services. Please note that emergency care is always covered.

For a copy of the health records that Healthfirst maintains about you, send a request specifying the records you’re seeking to:

Healthfirst Member Services
P.O. Box 5165, New York, NY 10274-5165
Fax: 1-212-801-3250

You can also make a request over the phone by calling Member Services at 1-844-347-5816, Monday to Friday, 8am—8pm or sending an email to
Forms@healthfirst.org.

To ask Healthfirst to share a copy of your electronic health records with an entity or another individual:

Complete the authorization form located here.

Send the completed authorization form and all relevant documentation to:

Healthfirst Member Services
P.O. Box 5165, New York, NY 10274-5165
Fax: 1-212-801-3250
Phone: 1-844-347-5816

You can also make a request over the phone by calling Member Services at 1-844-347-5816, Monday to Friday, 8am—8pm or sending an email to
Forms@healthfirst.org.

For additional information about the health records that Healthfirst maintains about you, please see the Notice of Privacy.

On January 10, 2022, the Biden-Harris Administration issued guidance requiring health insurance companies to cover the cost of over-the-counter (OTC) in-home COVID-19 tests for their members. Healthfirst is complying with that guidance: coverage began on January 15, 2022. For more information, visit hfcovidtests.org.

View this fact sheet if you have Medicaid and need information about COVID-19 vaccines, tests, and treatment.

You may have not submitted required documentation or missed the deadline, or you may no longer be eligible for your selected plan. Please contact us and we can help you regain coverage.

No. Once the Covid-19 Public Health Emergency (PHE) ends, you’ll need to renew coverage every year. The New York State of Health (NYSOH) and Healthfirst will contact you when it’s time to renew. Learn more about renewing your coverage here.

Certain plans have different renewal times, but we’ll reach out to make sure you have all the information you need. You can also use our online renewal guide or contact us for more information.

Unless you are enrolled in a Healthfirst Medicare plan, you’ll need to renew your insurance every year. You’ll get a reminder ahead of time asking you to renew your insurance plan. To renew your insurance, you can:

• Contact us. We can help you over the phone or make an appointment to visit you in your home or another location convenient to you.
• Visit one of our many Healthfirst Community Offices, where a representative will help you understand your health plan options

The easiest and fastest way to renew your plan is to contact us.

Required documentation for renewal varies from person to person. You’ll likely need:

• Proof of income
• Proof of address if your address has changed
• Proof of immigration status if your immigration status has changed or been renewed

No matter your Healthfirst plan, we’ll send a reminder when it’s time to renew. If you’re a Medicaid, Child Health Plus, Personal Wellness Plan, Essential Plan, Leaf or Leaf Premier member, you’ll also receive a notice from either NY State of Health (NYSOH), the Human Resources Administration (HRA), or your Local Department of Social Services (LDSS) before your anniversary date.

Make sure you open and read any renewal notices you receive to get the details about renewing your health insurance plan. Your coverage will be cancelled if you don’t renew when you are required to or don’t return documents by the requested date.

Unless you are enrolled in a Healthfirst Medicare plan, your healthcare coverage will expire and you’ll be without health insurance. If you get sick or injured, you won’t have health coverage—even in an emergency—and you’ll have to pay for any care received.

If you have additional questions, please call 1-800-342-3736, or email your questions to surprisemedicalbills@dfs.ny.gov.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance, and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or hospital, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in a stable condition.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. Providers of these services can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You can’t give up your protections for these other services if they are a surprise bill. Surprise bills are when you’re at an in-network hospital or ambulatory surgical facility and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided.

Services referred by your in-network doctor
Surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. You may need to sign a form (available on the Department of Financial Services’ website at www.dfs.ny.gov) for the full balance billing protection to apply.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact the New York State Department of Financial Services at (800) 342-3736 or surprisemedicalbills@dfs.ny.gov. Visit www.dfs.ny.gov for information about your rights under state law.

A member may get a surprise bill because:

• An in-network provider was not available
• An out-of-network provider gave the member services without his or her knowledge
• There was a medical problem or issue that came up at the time of the healthcare services
• The member was referred by an in-network provider without his or her written consent and without being informed that the referral may result in costs not covered by his or her health plan
• An in-network provider sent a sample taken during a member’s visit to an out-of-network lab or specialist
• The member’s primary doctor referred him or her to an out-of-network provider
• The member did not choose to get services from an out-of-network provider instead of from an available in-network provider

If the member chooses to receive services from an out-of-network provider, charges for the services are not considered surprise bills.

If you are a member and receive a bill that you believe is a surprise bill, please fill out this Surprise Bill Certification Form and submit to both Healthfirst and your provider. Sign, scan, and email it to claimsubmission@healthfirst.org or send by regular mail to:

Healthfirst Inc.,
P.O. Box 5165,
New York, NY 10274-5165

If we determine that you have received a surprise bill, you will not have to pay charges except for any applicable copays, coinsurance, or deductibles. This is sometimes called a “hold harmless” rule.

If a member gets emergency services from an out-of-network provider and Healthfirst paid that provider less than what was charged, the member will not have any costs greater than any applicable copays, coinsurance, or deductibles.

If you are a member and get a bill from an out-of-network provider for emergency services, please contact us at 1-888-250-2220.

If you are a provider and not satisfied with the amount Healthfirst has covered for a surprise bill or out-of-network emergency service, you can submit a case to an Independent Dispute Resolution Entity (IDRE). The Independent Dispute Resolution Entity (IDRE) reviews disputes with a licensed provider in an active practice in the same or similar specialty as the provider involved in the dispute. The IDRE will make a decision within 30 days of receipt of the dispute.

IDRE considers these factors when making a determination:

• Whether there is a large difference between the fee charged by the provider and (1) fees paid to the provider for the same out-of-network services provided to other patients, and (2) the fees paid by the health plan to pay back similar out-of-network providers for the same services in the same region
• The provider’s training, education, and experience, plus the usual charge for similar out-of-network services
• The complexity of the case
• Patient information
• The usual cost of the service

The review is admissible in court.

Please note: Out-of-network providers should provide to the member a bill and ask the member to complete a Surprise Bill Certification Form for any out-of-network services rendered to the member. If the member completes a Surprise Bill Certification Form, the provider cannot pursue the member for any other charges related to the service except for any applicable cost-sharing.

Providers may dispute the amount that Healthfirst pays them for emergency services through the IDRE process if they do not participate in our network.

To submit a claim to an Independent Dispute Resolution Entity (IDRE), a healthcare provider must:

• Visit the Department of Financial Services (DFS) web portal at myportal.dfs.ny.gov to file the case and obtain a tracking number
• Complete this application
• Send the application to the assigned Independent Dispute Resolution Entity

More information can be found on the DFS website at www.dfs.ny.gov/IDR.

An IDRE may advise a settlement if the health plan’s payment and the provider’s fee are very far apart. The IDRE decides the fee.

For disputes involving HMO or insurance coverage, the IDRE chooses either the non-participating provider bill or the health plan payment. For disputes submitted by uninsured patients, or patients with employer or union self-insured coverage, the IDRE decides the fee.

There may be several outcomes after the IDRE makes its decision, including:

• The provider pays the cost of the dispute resolution when the IDRE determines that the health plan’s payment is enough
• The health plan pays the cost of the dispute resolution when the IDRE determines that the provider’s fee is enough
• The provider and the health plan share the pro-rated cost when there is a settlement
• There may be a minimal fee to the provider or health plan if the dispute is found ineligible or incomplete

On November 12, 2020, the United States Departments of Health and Human Services, Labor and Treasury issued a Final Rule entitled Transparency in Coverage (the Rule) aimed at increasing the availability and transparency that consumers have to access health care pricing information through their health plans. Most non-grandfathered group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets are required to make available to the public, including consumers, researchers, employers, and third-party developers, machine-readable files that include detailed pricing information. The Rule also applies to Qualified Health Plans (QHP) and commercial issuers, but does not apply to Medicare Advantage, Medicare Supplement, Medicaid Managed Care, Child Health Plus or Essential Plan coverage, or vision- or dental-only plans.

In order to comply with the Rule, Healthfirst has made the required machine-readable files available using the Table of Contents links below. The data files are presented in the standardized formatting required by CMS and updated as required by the Rule. Please note that the formatting of these files is not meant for individual consumer use.

The first set of machine readable files available through the Table of Contents shows Healthfirst’s negotiated rates for all covered items and services between the plan and in-network providers. The second set of files available through the Table of Contents shows both the historical payments to, and billed charges from, out-of-network providers for providers with a minimum of twenty encounters.

Download the table of contents file for Marketplace Bronze, Silver, Gold, and Platinum plans

Download the table of contents file for Small Business Pro EPO and Pro Plus EPO Bronze, Silver, Gold, and Platinum plans

Download the Machine-readable file for Vision plans

Download the Machine-readable file for Dental plans

Download the Machine-readable file for Chiropractic plans

To the extent that you are a Healthfirst member and have questions about your plan’s coverage benefits, please reach out to our Member Services team (Contact Healthfirst) or refer to your plan materials.

• HIX = Healthfirst Health exchange marketplace plans Bronze, Silver, Gold, and Platinum plans
• HFIC = Healthfirst small business Pro EPO and Pro Plus EPO Bronze, Silver, Gold, and Platinum plans

• There are many ways you can receive your medical information from Healthfirst. Some of these ways are described in the “How to Request Your Records” which is located within the Coverage tab of this website. If you have a smartphone, you will soon be able to request your records through third-party apps.
• Healthfirst is required to deliver the following information through third-party apps:
  • adjudicated (paid) claims data;
  • encounters with capitated providers;
  • clinical data that Healthfirst maintains in our systems; and
  • drug benefit data (if applicable).
• Claims data is required to be sent within 1 business day after a claim it is adjudicated.
• Encounter and clinical data are required to be sent within 1 business day after Healthfirst receives the data.
• Drug benefit data are required to be sent within 1 business day after the effective date of the information or any updates.
• We are only required to send you data which we maintain from January 1, 2016 forward.

• There may be many apps from which to choose. You should consider the ones that will keep your data private and secure and that explain how they will handle and protect your data. Although Healthfirst recommends choosing an app with a transparent and robust privacy policy, the decision is ultimately yours.
• Some of the things you should look for in an app:
  • An easy-to-read privacy policy that includes:
    • how health data will be collected;
    • how non-health data will be collected (for example, location data);
    • if your health data will be stored, and for how long;
    • if your data is stored, will it be de-identified or made anonymous;
    • the data that might be shared and/or sold, to whom, and why;
    • how you can limit the app’s use and disclosure of your data;
    • if/how you can correct inaccurate data;
    • a process for collecting and responding to user complaints;
    • how users will be informed about changes to the privacy policy;
    • Information on the methods used to keep your health data secure;
    • an explanation of how to stop using the app to access your health data and how any data stored in the app will be deleted; and
    • documentation stating that the app developer will follow the Carin Code of Conduct, which is a set of principles for how healthcare organizations can share data with consumer applications.

• Healthfirst is a “covered entity” under the HIPAA Privacy and Security rules, which means we must comply with all of the HIPAA rules regarding the use and disclosure of your health information, as well your right to access, amend, or correct your data.
• For details on how Healthfirst protects your data, or to report a privacy issue, please see our privacy notices.
• You can also email the Privacy Office at hipaaprivacy@healthfirst.org, call the Privacy Office at 1-212-801-6299, or write to the Privacy Office at Healthfirst Privacy Office, P.O. Box 5183, New York, NY 10274-5183.

Note: Once your data is shared with your selected app, in most cases the data is no longer protected by HIPAA.

• If you believe that we have violated your privacy rights, you have the right to file a complaint with us. You may file a complaint with us by emailing, calling or writing the Privacy Office:
  • Email Healthfirst at HIPAAPrivacy@healthfirst.org
  • Write to the Healthfirst Privacy Office, P.O. Box 5183, New York, NY 10274
  • Call us at 1-212-801-6299

• The Office for Civil Rights (“OCR”) is responsible for the enforcement of the HIPAA rules and is the agency to contact with a complaint that cannot be resolved directly with Healthfirst. To file a complaint you can:
  • visit the online portal at hhs.gov/ocr/smartscreen/main.jsf;
  • write to the Office for Civil Rights, US Department of Health and Human Services, Jacob Javits Federal Building, Suite 3312, New York, NY 10278;
  • call the OCR Hotline at 1-800-368-1019; or email OCR at ocrmail@hhs.gov
  • email OCR at ocrmail@hhs.gov

• Third-party apps are not subject to the HIPAA rules, but to the Federal Trade Commission (“FTC”) under the FTC Act. The FTC Act protects against “unfair or deceptive acts or practices” in or affecting commerce. Examples of these include:
• An app sharing personal data without permission even if its privacy policy says it would not do so.
• An app’s website containing statements in its marketing materials, FAQs, etc. that are untrue.
• Complaints to the FTC can be made online at ftc.gov or by calling the FTC’s Consumer Response Center at 1-877-382-4357.