Healthy New York program
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Healthy New York - Introduction

The Health Care Reform Act of 2000 introduced the Healthy NY program to provide more affordable health insurance to New Yorkers who need it most. Healthy NY, in partnership with HMOs and other insurance companies in New York State, offers comprehensive health insurance to small businesses. DFS oversees the program.


Small Business Owners

Healthy NY includes comprehensive coverage for essential health benefits including inpatient and outpatient hospital services, physician services, maternity care, preventive health services, diagnostic services, mental health services, chiropractic care, prescription drugs, ambulance and emergency services.

As of January 1, 2014, Healthy NY no longer provides coverage for individuals or sole proprietors. Instead, the New York State of Health Marketplace can help individuals and sole proprietors shop for and enroll in health insurance. You may also qualify to receive assistance to help pay for insurance offered through the Marketplace.

For more information about Small Business Resources, please visit that section here.

Guidance for Insurers Participating in Healthy NY

The DFS issues guidance to insurance companies participating in Healthy NY to assist in program implementation. Below are a selection of Healthy NY guidance memoranda. This is not an exhaustive list of all guidance memos.

Date Guidance Subject

September 2021

Updated Small Employer Wage Level

October 29, 2019

Guidance for Insurers Participating in Healthy NY

October 12, 2017

Guidance for Insurers Participating in Healthy NY section

July 28, 2015

Employer Eligibility for Healthy NY coverage issued or renewed on or after January 1, 2016, New Healthy NY Recertification Form, Loss of Eligibility for Healthy NY Coverage

June 20, 2013

Small Employer Groups

February 7, 2013

Federal Health Care Reform Benefit and Annual Limit Updates, Spouse as Primary Policyholder, High Deductible Health Plan (HDHP) Deductible Amounts, Current Wage Level for Small Employers, 2013 Individual Income Eligibility Levels

Eligibility

To participate in Healthy NY, a small business must meet all of the following criteria:

  1. The business must be located within New York State.
  2. The business must have had 1-50 Full-Time Equivalent (FTE) employees over the previous calendar year.
  3. At least 30% of the employees must earn $45,450 or less in annual wages. The wage level is adjusted annually for inflation.
  4. The business must not have provided group health insurance coverage to its employees within the last 12 months.

    A business is considered to have provided health insurance if the business has arranged for comprehensive coverage that includes both hospital and medical coverage and contributed at least $50 per employee per month towards health insurance ($75 if the business is located in the Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk or Westchester counties).

    The business may still be eligible for Healthy NY if:

    • The business arranged for health insurance coverage for employees but did not contribute more than the previously noted amounts.
    • The business arranged for health insurance coverage for employees but it was not comprehensive (i.e., only medical benefits or only hospital benefits but not both).
    • Individual employees had insurance coverage through other sources, such as individually-purchased coverage, a public program, COBRA from prior employment or a spouse’s job.
    • The business owner has coverage for himself or herself but did not provide the coverage to employees.
    • The business provided insurance coverage to one or more classes of employees and now wants to provide coverage to additional classes of employees. Classes of employees may be based on wages, method of payment (e.g., hourly vs. salaried), job duties or job location.

If the business meets the four criteria above and 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 $45,450 (adjusted annually) or less. A small employer may count employees who have health insurance coverage through another source, such as a spouse or other government program, towards the 50% participation requirement.
  • The employer will contribute at least 50% of the premium.
  • At least one eligible employee earning $45,450* or less enrolls.
  • The employer will offer Healthy NY to all employees who are working 20 or more hours per week and earning $45,450 (adjusted annually) or less. If the business meets the the four criteria above.

Tax Advantages and Benefits of Providing Health Insurance

Significant tax advantages may be available to your business by offering health insurance coverage. Health insurance premiums that businesses pay on their employees’ behalf are generally 100% tax deductible. Providing health insurance coverage may also result in reduced payroll taxes. Additionally, if a business establishes a Section 125 plan, employees’ share of the premiums can be paid with pre-tax dollars, resulting in tax savings for both employees and the business.

Benefit Package

Network-Based Coverage

The health plans that offer Healthy NY coverage have their own medical provider networks. This means that benefits are provided a network of medical providers. You must use the doctors and health care providers who participate in your insurance company’s network, except in an emergency. Contact your health plan directly to confirm whether your health care providers are in their network.

Covered Benefits

This is not intended to be a complete list of covered benefits.  Please refer to your health plan coverage documents for a full description of covered benefits.

  • Office Visits: Primary Care and Specialist
  • Preventive Care: Well-Child Care, Adult Annual Physical Examinations, Adult Immunizations, Well-Woman Examinations, Mammograms, Family Planning & Reproductive Health Services, Bone Mineral Density Testing, and Screening for Prostate Cancer
  • Emergency and Urgent Care:& Ambulance Services, Emergency Department and Urgent Care Center
  • Professional Services and Outpatient Care: Advanced Imaging Services, Allergy Testing and Treatment, Ambulatory Surgery Center, Anesthesia Services, Cardiac & Pulmonary Rehabilitation, Chemotherapy, Chiropractic Services, Diagnostic Testing, Dialysis, Habilitation Services, Home Health Care, Infertility Treatment, Infusion Therapy, Inpatient Medical Visits, Laboratory Procedures, Maternity & Newborn Care, Preadmission Testing, Diagnostic and Therapeutic Radiology Services, Rehabilitation Services, Second Opinions, Surgical Services
  • Additional Services, Equipment & Devices: Autism Spectrum Disorder Diagnosis and Treatment, Hospice, Diabetic Equipment andSupplies, Durable Medical Equipment and Braces, Hearing Aids, Cochlear Implants, Medical Supplies and Prosthetics
  • Inpatient Services & Facilities: Hospital Services (including Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, and End of Life Care), Skilled Nursing Facility, and Rehabilitation Services
  • Mental Health and Substance Use Services: Inpatient and Outpatient
  • Prescription Drugs
  • Wellness
  • Pediatric Dental & Vision

Cost Sharing 2020

Please consult your health plan coverage documents for a more extensive description of your cost sharing responsibility.  Some examples of copayments and coinsurance are included below.

Deductible

$600 individual / $1,200 family

Maximum out of pocket costs

$4,000 individual / $8,000 family

Primary Care Physician (PCP) visit

$25

Specialist visit

$40

Preventive Care

No cost sharing

Ambulance

$150

Emergency Room visit

$150 (waived if admitted)

Urgent Care

$60

Chemotherapy, radiation therapy

$25 per visit

Chiropractic care

$40

Physical therapy, occupational therapy, speech therapy

$30

Diagnostic and routine laboratory and pathology

$40

Diagnostic and routine imaging

$40

Surgical Services – inpatient, outpatient and surgicenters

$100

DME / Medical supplies

20% coinsurance

Hearing aids

20% coinsurance

Inpatient Facility / Skilled Nursing / Hospice

$1,000 per admission

Mental Health & Substance Use Disorder Services

$1,000 per admission (inpatient)
$25 (outpatient)

Prescription drugs
     Ask your health plan about mail order.     

$10 generic
$35 formulary brand
$70 non-formulary brand

Pediatric dental - office visit

$25

Pediatric vision – eye exam visit
    Prescribed lenses and frames or contact lenses

$25
20% coinsurance

Insurers and Rates

Many different insurance companies offer Healthy NY.  The chart below contains links to a list of insurance companies that offer Healthy NY in each county, contact information and premium rates. Rates are current as of January 1, 2022 and may vary depending upon the month in which you enroll. To verify the rates listed, please contact the insurance company directly.

County Links

Albany Franklin Oneida Seneca
Allegany Fulton Onondaga Steuben
Bronx Genesee Ontario St. Lawrence
Broome Greene Orange Suffolk
Cattaraugus Hamilton Orleans Sullivan
Cayuga Herkimer Oswego Tioga
Chautauqua Jefferson Otsego Tompkins
Chemung Kings Putnam Ulster
Chenango Lewis Queens Warren
Clinton Livingston Rensselaer Washington
Columbia Madison Richmond Wayne
Cortland Monroe Rockland Westchester
Delaware Montgomery Saratoga Wyoming
Dutchess Nassau Schenectady Yates
Erie New York Schoharie  
Essex Niagara Schuyler

Who Can be Covered

In addition to offering coverage for employees, your business may choose offer coverage to employees’ families. As the business owner, you do not have to contribute to the cost of premiums for employees’ dependents. By making coverage available to employees’ dependents, you can allow them to access health insurance coverage at affordable group rates.

If your business offers Healthy NY, you may offer coverage to:

  • Employees, including the business owner;
  • Employees’ same-and opposite-sex spouses, if residing in the household;
  • Employees’ domestic partners, if you wish to make domestic partner coverage available (the employer may also decide whether to make coverage available to same-sex domestic partners, opposite-sex domestic partners, or both);
  • Employees’ children to age 26.

Children do not need to live in the employee’s household in order to be covered. Stepchildren may also be covered.

You may be able to purchase coverage for certain eligible children through the age of 29 via an "Age 29" Dependent Coverage Extension. Contact your insurance company for more information regarding eligibility and the cost of the coverage

How to Apply

Applications

You may print out the application, complete it and mail it, or complete the application online and then print it out and mail it. Applications cannot be submitted online or via e-mail.

How to Submit Your Application

  • Complete and sign the application.
  • Enclose a check for the first month’s premium, made payable to the insurer to which you are applying. Mail your completed application directly to the insurance company through which you want Healthy NY coverage. Please do not mail your application to the Department of Financial Services. This will delay the application process.

For a list of insurance companies, their addresses, and premium rates, visit the Insurers and Rates section above.

When Coverage will Start

If the insurance company receives your completed application and first month’s premium payment by the 20th of the month, coverage will start the first of the following month.

Application Status

DFS does not process Healthy NY applications. Please direct all questions regarding application status to the insurance company to which you applied. For your insurance company’s contact information, visit the Insurers and Rates section above.

If you are unable to print the application, please contact DFS at (800) 342-3736 (Monday through Friday, 8:30 AM to 4:30 PM) or email [email protected] to request an application.

Recertification and Changes

Recertification

Once a year, you must recertify that the business continues to meet the eligibility requirements of the Healthy NY program. The recertification date is on your policy’s annual renewal date. Your insurance company will provide you with the recertification form at least 90 days before your annual renewal date.

At recertification, you must confirm that:

  • The business must have had 50 or fewer full-time equivalent employees in the prior calendar year,
  • The business will continue to contribute at least 50% of the cost of premiums for full-time, non-seasonal employees, and
  • At least 30% of employees earn $45,450 or less in annual wages (wage levels are adjusted annually).

If you do not complete and return the recertification form by the due date, then your business’ coverage will terminate. If the business does not continue to meet the eligibility requirements of the program at recertification, then it will not be able to continue in the program. Your insurance company must provide you with at least 45 days written notice that coverage will end due to not meeting the eligibility requirements.

Mid-Year Changes

Mid-year changes in group size, wage levels and employee participation will not result in immediate termination of Healthy NY coverage. If the business does not meet the eligibility requirements at the time of recertification, it will be unable to continue in the program.

Changing Insurers

You may change insurance companies at any time.

To do so, you must reapply to the Healthy NY program and send your completed application and premium check to the insurance company with which you want coverage. The business must meet the eligibility criteria at the time of application.

For information on which insurance companies offer Healthy NY in your county and premium rates, visit the Insurers and Rates page. If the insurance company receives a completed application and first month’s premium payment by the 20th of the month, coverage will start the first of the following month.

You will also need to terminate your existing coverage according to the terms of the contract. Usually you must give at least one month prior notice.

It is not possible to transfer enrollment with one insurance company to another insurance company.

Other Resources

New York State of Health: The Official Health Plan Marketplace

NY State of Health is an organized marketplace designed to help people shop for and enroll in health insurance coverage. Individuals, families and small businesses can use the Marketplace to help them compare insurance options, calculate costs and select coverage. The Marketplace has a section specifically for small businesses called “The Small Business Marketplace” that can make it simple and easy for you to offer high quality, affordable health insurance coverage to your employees while taking advantage of the small business health care tax credit. For more information, please contact the the Small Business Marketplace by phone at (855) 355-5777 or visit the NYSOH Small Business Marketplace online.

Child Health Plus

New York State has a health insurance plan for children through age 18 called Child Health Plus. Child Health Plus is run by the Department of Health and provides free or reduced-cost coverage. For more information on Child Health Plus eligibility and covered services, please visit the Department of Health or call (800) 698-4543. You can apply for Child Health Plus coverage through the New York State of Health Marketplace.

OCHIA

The Office of Citywide Health Insurance Access (OCHIA) is a resource for small businesses and people living in the metropolitan New York area that helps people determine if they qualify for any public health insurance programs, and if not, helps to find other affordable insurance. It also helps small businesses find coverage. For more information, please visit the OCHIA website.