Frequently Asked Questions
Health insurance can help you stay healthy. Even if you’re in good health, health insurance can help you get access to primary care, to emergency treatment, and to free preventive services. You never know when an accident might happen, or if you’ll get sick and need to go to the hospital. If and when that day comes, the costs could be too expensive, and you and your family might not be able to afford the care you need. That’s where health insurance comes in. It’s good for your health, your wallet, and your future.
There’s no penalty for not having health insurance; however, you never know when you may need to go to the doctor or hospital. Having health insurance helps lower the costs associated with both well and emergency visits. We have plans for all types of families and income levels; let us help find the Healthfirst plan that’s right for you. Use our plan recommendation tool or contact us for help.
Taking advantage of your benefits can help you save money on healthcare costs. To help you lower your overall health insurance costs, you should always:
- Use your no cost benefits, such as annual checkups, to help keep you healthy and identify potential risks early.
- Make sure you see an in-network doctor or facility for treatment to avoid out-of-pocket costs
- Visit an urgent care center for non-emergency issues such as colds or flu, sprains, and wounds
- Choose 90-day prescription refills
- Use your telemedicine benefit if it’s included with your health plan
The cost of health insurance varies by plan, income, and family size. You can see what Healthfirst plans may cost you by using our plan recommendation tool.
Your income, family size, and the plan you select will also determine if you’re eligible to get help paying for your health insurance. To find out if you qualify, you can:
- Contact us by phone or fill out a form for us to contact you
- Visit one of our many Healthfirst Community Offices, where a representative will help you understand your health plan and subsidy options
Healthfirst is a not-for-profit community organization sponsored by some of the most prestigious and nationally recognized hospitals and medical centers in New York. With more than a million members and growing, Healthfirst has been serving communities in New York City for more than 25 years. With access to thousands of doctors and specialists, you’re sure to find the service you need nearby. Each of our community offices is fully staffed with representatives who can answer questions—in many different languages—about our health insurance plans and programs, whether you’re a member or not.
New York State created a health insurance marketplace, or exchange, called NY State of Health, to help individuals and small businesses shop for health insurance. The NY State of Health website opened on October 1, 2013. On the NY State of Health website, consumers can shop for health plans like Healthfirst Leaf Plans.
On the NY State of Health website, you can:
- Compare plans and choose the one that best fits your needs and budget
- Fill out an application to enroll in any plan offered
- Get help online, over the phone, or in person. If you need help enrolling, please call Healthfirst at 1-888-250-2220, Monday to Friday, 8am–8pm.
- You can find out which tax credits and other subsidies you may be eligible for to help lower the cost of your healthcare
People without internet access can also call the NY State of Health customer service center at 1-855-355-5777.
Yes! Healthfirst Leaf Plans, Healthfirst Essential Plans, Healthfirst Medicaid Managed Care, and Healthfirst Child Health Plus are on NY State of Health. These plans are for individuals and families who live in New York City, Nassau County, Suffolk County, or Westchester County, and they’re designed to meet all income and coverage needs.
Use our plan recommendation tool to find the plan that’s right for you.
Prescription drugs are:
- Prescribed by a doctor
- Bought only at a pharmacy
- Prescribed for and used by only one person
Over-the-counter (OTC) drugs are:
- Drugs that do NOT require a doctor’s prescription, such as aspirin, antacids, or vitamins
- Can be purchased by anyone at any store that sells them
Both prescription and OTC drugs are carefully approved and regulated by the U.S. Food and Drug Administration (FDA). Whether you take prescription or OTC drugs, you should always:
- Read the label carefully
- Understand how to take the drug
- Take only the recommended amount at the recommend time(s)
Yes. Generics are the same as brand name drugs in many ways:
- How you take the medicine (for example, pill or liquid)
- How it works
- How the medicine should be used
This is required by the U.S. Food and Drug Administration (FDA). The difference is that generic drugs usually cost much less than brand name drugs. Not all brand name drugs are available as generic versions.
To find out more about a specific drug, you can use our drug search tool.
Premium payments are due by the 1st of each month except for Child Health Plus payments which are due the last day of the month. You’ll receive an invoice in the mail every month that contains more detail. If you have questions regarding your bill, please contact us.
Yes. At Healthfirst, our representatives speak Spanish, Chinese, Russian, and many other languages. We can even make an appointment to visit you in your home or another location convenient to you. Contact us to see all the ways we can help.
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.
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
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)
- 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 HFDocFinder to find a pharmacy 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, hospital, or pharmacy.
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.
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.
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:
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.
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.
A surprise bill is when a member gets services from an out-of-network provider at an in-network hospital or other center and receives a bill for those services.
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 Assignment of Benefits form. Sign, scan, and email it to email@example.com or send by regular mail to:
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 co-pays, 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 co-pays, coinsurance, or deductibles.
In some cases, the costs the member owes may increase. This may happen if an Independent Dispute Resolution Entity (IDRE) decides that Healthfirst must pay the out-of-network provider an amount higher than what Healthfirst originally paid.
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 complaint 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 an Assignment of Benefits Form for any out-of-network services rendered to the member. If the member completes an Assignment of Benefits 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 IDR process if they do not participate in our network.
This right to dispute can be limited. The following services are ineligible for the independent dispute resolution process if the bill does not exceed 120% of the usual and customary cost and the disputed fee is less than $613.50 (adjusted annually for inflation) after any applicable co-pays, coinsurance, or deductibles are applied.
CPT Codes 99281 – 99285, 99288, 99291 – 99292, 99217 – 99220, 99224 – 99226, and 99234 – 99236
To submit a claim to an Independent Dispute Resolution Entity (IDRE), a healthcare provider must:
- Visit the Department of Financial Services (DFS) website to receive a file number
- Complete this application
- Send the application to the assigned Independent Dispute Resolution Entity
IDRE may advise a settlement if the health plan’s payment and the provider’s fee are very far apart. 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