Enrolling with NY State of Health

Option 1: Employer Begins Process on NY State of Health (NYSH)

  • Step 1: Employer downloads PDF SHOP application on NY State of Health without having to create an account, fills it out and mail it to the Marketplace
  • Step 2: NYSH reviews application and makes an eligibility determination by ensuring employer has attested to eligibility criteria and signed the application
  • Step 3: NYSH calls employer and sends eligibility notice along with next steps
  • Step 4: Employer reviews plan and issuer (insurance company) information on NY State of Health and contacts a licensed broker or issuer directly to begin the enrollment process
  • Step 5: Issuer has employer complete issuer-specific enrollment process and provides employer or agent/broker with exact premium quote
  • Step 6: Issuer calls NYSH employer contact center to verify employer and employees are eligible to participate in NYSH and that the group meets any applicable minimum participation requirement (MPR). Enrollment deadline is the 15th of the month, though deadline may be extended voluntarily by issuers. If employer is unable to proceed with enrollment because it fails MPR, then NYSH will notify employer and provide appeals information
  • Step 7: Issuer collects first month’s premium payment by the coverage effective date. If employer fails to make initial payment, issuer calls NYSH employer contact center about account status
  • Step 8: Issuer notifies employer and employees of successful enrollment in Qualified Health Plan (QHP) and/or Qualified Dental Plan (QDP)
  • Step 9: NYSH and IRS verify QHP and QDP enrollment on monthly audit file
  • Step 10: Employer contacts issuer to add or drop employees and dependents
  • Step 11: NYSH updates employee roster after receiving monthly audit file and contacts employer to verify enrollment changes

 

Option 2: Employer Begins Process with Issuer (Insurance Provider)

  • Step 1: Employer calls issuer or agent/broker wanting more information about NYSH
  • Step 2: Employer downloads PDF SHOP application on NY State of Health or on website of issuer or agent/broker. Issuer, agent/broker or employer, fills it out and sends in  application to the Marketplace
  • Step 3: Issuer has employer complete issuer-specific enrollment process and provides employer or agent/broker with exact premium quote
  • Step 4: Issuer accepts enrollment based on a provisional NYSH eligibility determination. Alerts employer NYSH will send an official eligibility notification
  • Step 5: Issuer collects first month’s premium payment by the coverage effective date. If employer fails to make initial payment or issuer determines a group may not enroll, issuer calls NYSH employer contact center about status of account
  • Step 6: Issuer notifies employer and employees of successful enrollment in QHP and/or QDP
  • Step 7: NYSH reviews application when it arrives and makes an eligibility determination by ensuring employer has attested to eligibility criteria and signed the application
  • Step 8: NYSH calls employer and sends official eligibility notice. If employer is deemed ineligible, then NYSH will notify employer and provide appeals information. NYSH will also notify issuer about status of account. Issuer may transfer enrollees to non-NYSH plan if they are determined not eligible for NYSH
  • Step 9: NYSH verifies employee eligibility and QHP and QDP enrollment on monthly audit file
  • Step 10: Employer contacts issuer to add or drop employees and dependents
  • Step 11: NYSH updates employee roster after receiving monthly audit file and contacts employer to verify enrollment changes
  • Issuers may direct employers and agents/brokers to the Marketplace (Option 1) if they do not want to start the enrollment process without a NYSH eligibility determination