New York Health Insurance Plans & Enrollment Assistance
Navigate your health insurance options with confidence. We can help you explore coverage through the NY State of Health Marketplace for individuals, families, and small businesses.
Why Health Insurance Matters
Medical expenses are a leading cause of financial hardship for American families. Health insurance helps protect you and your family from unexpected medical costs and provides access to preventive care that can catch health issues early. Under the Affordable Care Act, insurers cannot deny coverage or charge more based on pre-existing conditions, and young adults can stay on a parent's plan until age 26.
What Is Health Insurance?
Health insurance is an agreement between you and an insurance company where you pay a monthly premium in exchange for the insurer covering a portion of your medical expenses. This may include doctor visits, hospital stays, prescription medications, preventive care, mental health services, and more.
In New York, most health insurance for individuals and families is available through the NY State of Health Marketplace, the state's official health plan marketplace established under the Affordable Care Act (ACA). The marketplace offers Qualified Health Plans (QHPs) from multiple insurance carriers, and many New Yorkers may qualify for financial assistance to help lower their monthly costs.
New York also offers several state-specific programs including the Essential Plan (low-cost coverage with $0 premiums for eligible New Yorkers), Child Health Plus (coverage for children under 19), and expanded Medicaid for adults earning up to 138% of the federal poverty level.
Key Health Insurance Terms
- Premium: The monthly amount you pay for your plan
- Deductible: What you pay out-of-pocket before the plan starts paying
- Copay: A fixed amount for a specific service (e.g., $25 per visit)
- Coinsurance: Your percentage share of costs after meeting your deductible
- Out-of-Pocket Maximum: The most you pay in a year before the plan covers 100%
- Network: The doctors, hospitals, and pharmacies your plan contracts with
What Health Insurance Typically Covers & Common Exclusions
Essential Health Benefits (Required by ACA)
All marketplace plans must cover these 10 categories:
- ✓Outpatient care — Doctor visits, urgent care, and ambulatory services
- ✓Emergency services — ER visits covered at in-network rates even out-of-network
- ✓Hospitalization — Inpatient care including surgery and overnight stays
- ✓Maternity & newborn care — Prenatal, delivery, and postpartum services
- ✓Mental health & substance use — Behavioral health treatment and counseling
- ✓Prescription drugs — At least one drug in each category and class
- ✓Rehabilitative services — Physical therapy, occupational therapy, and devices
- ✓Lab services — Blood work, imaging, and diagnostic tests
- ✓Preventive & wellness — Screenings, immunizations, and chronic disease management
- ✓Pediatric services — Including dental and vision care for children
Common Exclusions
These services are often not covered (varies by plan):
- ✗Cosmetic surgery — Elective procedures for aesthetic purposes (reconstructive surgery after injury may be covered)
- ✗Adult dental & vision — Routine adult dental and vision care typically require separate plans
- ✗Experimental treatments — Procedures or drugs not yet approved by the FDA
- ✗Weight loss programs — Some weight management services and bariatric surgery may be excluded
- ✗Alternative therapies — Acupuncture, massage therapy, and naturopathy may not be covered
- ✗Out-of-network care — HMO and EPO plans generally do not cover non-emergency out-of-network services
Always review your plan's Summary of Benefits and Coverage (SBC) for specific exclusion details.
Need Help Understanding Your Options?
We can walk you through your coverage options at no cost. Let us help you compare plans and understand what may be available to you.
Understanding Health Plan Types
Health plans are organized into network types that affect which doctors you can see, whether you need referrals, and how much you pay for out-of-network care. Here are the four main types available through the NY marketplace: (HealthCare.gov plan types)
HMO (Health Maintenance Organization)
- Network: Must use in-network providers (except emergencies)
- PCP Required: Yes — you choose a primary care physician
- Referrals: Typically required to see specialists
- Out-of-Network: Generally not covered
- Best for: Those comfortable using a defined network who want lower premiums
PPO (Preferred Provider Organization)
- Network: In-network preferred, but out-of-network providers allowed
- PCP Required: No
- Referrals: Not required for specialists
- Out-of-Network: Covered at higher cost to you
- Best for: Those wanting maximum flexibility in provider choice
EPO (Exclusive Provider Organization)
- Network: Must use in-network providers (except emergencies)
- PCP Required: Usually not required
- Referrals: Usually not required
- Out-of-Network: Generally not covered
- Best for: Those who want flexibility within a network without referral requirements
POS (Point-of-Service)
- Network: In-network preferred, but out-of-network available
- PCP Required: Yes
- Referrals: Usually required for specialists
- Out-of-Network: Covered at higher cost to you
- Best for: Those wanting some out-of-network flexibility with managed care coordination
Understanding the Metal Tier System
Marketplace plans are organized into four "metal" tiers based on actuarial value — the percentage of average health care costs the plan covers. The tiers do not reflect quality of care; all tiers cover the same essential health benefits. (Learn more at HealthCare.gov)
| Metal Tier | Plan Pays | You Pay | General Characteristics |
|---|---|---|---|
| Bronze | ~60% | ~40% | Lower monthly premiums, higher out-of-pocket costs. May work for those who are generally healthy and want a safety net for major medical events. |
| Silver | ~70% | ~30% | Moderate premiums and out-of-pocket costs. Required to qualify for cost-sharing reductions (CSR), which can increase actuarial value to 73%, 87%, or even 94% based on income. |
| Gold | ~80% | ~20% | Higher monthly premiums, lower out-of-pocket costs. May be suitable for those who use health care services frequently. |
| Platinum | ~90% | ~10% | Highest monthly premiums, lowest out-of-pocket costs. Typically has very low deductibles and the most predictable costs. |
Note: Actuarial value percentages are averages across a standard population, not a guarantee of your individual cost share.
New York State Health Insurance Programs
New York offers several programs beyond standard marketplace plans that may provide coverage depending on your income, age, and household size. Unlike Qualified Health Plans, these programs allow enrollment year-round.
Essential Plan
The Essential Plan is a low-cost health insurance option for New Yorkers who earn up to 250% of the federal poverty level. As of April 2025, eligibility has been expanded to include this higher income threshold. (Essential Plan details)
- ✓ $0 monthly premiums for most eligible enrollees
- ✓ No deductible — coverage starts immediately
- ✓ Comprehensive benefits including dental and vision
- ✓ Year-round enrollment
- ✓ Over 1.7 million New Yorkers enrolled as of January 2026
Child Health Plus
Child Health Plus provides health coverage for children under age 19 who are New York State residents and do not qualify for Medicaid. (Eligibility details)
- ✓ Free or low-cost coverage depending on family income
- ✓ Covers doctor visits, immunizations, and more
- ✓ Includes dental, vision, and prescription drug coverage
- ✓ Year-round enrollment available
Medicaid
New York expanded Medicaid under the ACA, providing comprehensive health coverage to adults with income up to 138% of the federal poverty level. As of mid-2025, over 6.5 million New Yorkers were covered through Medicaid/CHIP. (NY Medicaid details)
- ✓ Comprehensive coverage at little to no cost
- ✓ Income-based eligibility (up to 138% FPL for adults)
- ✓ Year-round enrollment
- ✓ Covers doctor visits, hospital care, prescriptions, and more
How to Enroll in Health Insurance
Open Enrollment Period
For Qualified Health Plans (QHPs), Open Enrollment typically runs from November 1 through January 31 each year. To have coverage start on January 1, you generally need to enroll by December 15. The Essential Plan, Child Health Plus, and Medicaid allow year-round enrollment. (2026 Open Enrollment details)
Existing NY State of Health Account
If you already have an account with the NY State of Health Marketplace, log in and choose "Manage Broker/Navigator" to add Mathieu Steele as your Broker. If asked for the county, select "Ontario." If asked for the Agency, choose "Steele Stan Agency."
New to NY State of Health
If you don't yet have an account, we can help you set one up. Please complete this authorization form so we can assist you with the enrollment process.
Schedule an Appointment
Meet with one of our licensed health insurance agents who can walk you through available plans, help you understand potential financial assistance, and assist with enrollment. Call us at 585-657-6101 or schedule an appointment online.
Gather Your Information
Have the following ready for your enrollment appointment: Social Security numbers for all household members, income information (pay stubs, tax returns), current employer and insurance details, and immigration documents (if applicable).
Special Enrollment Periods
If you miss Open Enrollment, you may still qualify for a Special Enrollment Period (SEP) if you experience a qualifying life event. You generally have 60 days from the event to enroll. (NY State of Health SEP information)
Loss of Coverage
Losing employer coverage, aging off a parent's plan, losing Medicaid/CHIP eligibility, or other involuntary loss of health coverage.
Marriage or Domestic Partnership
Getting married or entering a domestic partnership qualifies you to add your spouse or partner to your plan or enroll in a new plan.
Birth or Adoption
Having a baby, adopting a child, or being placed with a foster child qualifies you to add the child and update your coverage.
Change in Residence
Moving to a new ZIP code or county where different plans are available. Moving solely for medical treatment does not qualify.
Income Change
Gaining or losing eligibility for financial assistance, Medicaid, or the Essential Plan due to an income change.
Other Qualifying Events
Becoming a U.S. citizen, leaving incarceration, or being affected by a natural disaster may also qualify. Contact us for details.
Preventive Care Covered at No Cost
Under the ACA, all marketplace plans must cover certain preventive services at no cost to you when provided by an in-network provider — you pay no copay, coinsurance, or deductible. (Full list at HealthCare.gov)
For All Adults
- ✓ Annual wellness visits
- ✓ Blood pressure screening
- ✓ Cholesterol screening
- ✓ Depression screening
- ✓ Type 2 diabetes screening
- ✓ Immunizations (flu, hepatitis, tetanus, etc.)
- ✓ HIV screening
- ✓ Colorectal cancer screening (age 45+)
- ✓ Lung cancer screening (for eligible adults)
For Women
- ✓ Mammograms (age 40+)
- ✓ Cervical cancer screening
- ✓ Prenatal care visits
- ✓ Contraception methods and counseling
- ✓ Breastfeeding support and supplies
- ✓ Osteoporosis screening (age 60+)
- ✓ Well-woman visits
Frequently Asked Questions
When is Open Enrollment for NY health insurance?
Open Enrollment for Qualified Health Plans through NY State of Health typically runs from November 1 through January 31 each year. To get coverage starting January 1, you generally need to enroll by December 15. Important: The Essential Plan, Child Health Plus, and Medicaid offer year-round enrollment, so you can apply anytime.
What is the difference between Bronze, Silver, Gold, and Platinum plans?
These metal tiers reflect how costs are shared between you and the plan. Bronze plans cover about 60% of costs (lower premiums, higher out-of-pocket). Silver plans cover about 70%. Gold plans cover about 80%. Platinum plans cover about 90% (higher premiums, lower out-of-pocket). All tiers cover the same essential health benefits. If you qualify for cost-sharing reductions based on income, you must choose a Silver plan to receive those extra savings.
What is a premium, deductible, copay, and coinsurance?
A premium is the monthly amount you pay for your health plan regardless of whether you use services. A deductible is the amount you pay out-of-pocket each year before your plan starts paying its share. A copay is a fixed dollar amount you pay for a specific service (e.g., $25 for a doctor visit). Coinsurance is your percentage share of costs after meeting your deductible (e.g., you pay 20%, the plan pays 80%).
Can I get health insurance if I missed Open Enrollment?
You may qualify for a Special Enrollment Period if you experience a qualifying life event such as losing other health coverage, getting married, having a baby, or moving to a new area. You typically have 60 days from the event to enroll. Additionally, the Essential Plan, Child Health Plus, and Medicaid allow year-round enrollment in New York regardless of Open Enrollment dates.
What is the Essential Plan in New York?
The Essential Plan is a health insurance option available exclusively through NY State of Health for New Yorkers who earn up to 250% of the federal poverty level. It features $0 monthly premiums for most eligible enrollees, no deductible, and comprehensive benefits including dental and vision coverage. Over 1.7 million New Yorkers were enrolled in the Essential Plan as of January 2026. Enrollment is available year-round.
Are preventive services covered at no cost?
Yes. Under the Affordable Care Act, all marketplace health plans must cover certain preventive services at no cost when provided by an in-network provider. This includes annual wellness visits, immunizations, cancer screenings (mammograms, colonoscopies), blood pressure and cholesterol checks, and many other services. No copay, coinsurance, or deductible applies to these preventive services.
Can I keep my doctor if I change health plans?
Whether you can keep your doctor depends on the plan's provider network. HMO and EPO plans require you to use in-network providers (except for emergencies). PPO and POS plans allow out-of-network visits at a higher cost. Before enrolling, check the plan's provider directory to confirm your preferred doctors, specialists, and hospitals are included. We can help you compare plan networks during your consultation.
Related Coverage Options
Health insurance is one part of a comprehensive protection plan. Consider these related coverage options:
Medicare
Federal health coverage for adults 65+, or those with certain disabilities. Includes Original Medicare, Advantage, and supplement options.
Essential Plan
Low-cost health coverage for eligible New Yorkers with $0 premiums, no deductible, and comprehensive benefits including dental and vision.
Disability Insurance
Income protection if you become unable to work due to illness or injury. Helps cover living expenses while you recover.
Life Insurance
Financial protection for your family in the event of your passing. Term and permanent options available to fit different needs.
Other Health-Related Coverage
Important Information
This information is provided for general educational purposes only and does not constitute insurance advice or policy recommendations. Coverage features described are examples and may not be available in all policies or from all carriers. Actual coverage is subject to the terms, conditions, and exclusions of the policy as issued. Eligibility for programs, premium tax credits, and cost-sharing reductions is determined by NY State of Health based on your application. Please consult with a licensed insurance professional to discuss your specific coverage needs and options. Stan Steele Agency is licensed in New York State.
Let Us Help You Explore Your Health Insurance Options
Choosing health insurance can feel overwhelming. Our licensed professionals can help you compare plans, understand your eligibility for financial assistance, and walk you through the enrollment process at no cost to you.
How We Can Help:
- ✓ Free enrollment assistance and plan comparison
- ✓ Help determining financial assistance eligibility
- ✓ Guidance through NY State of Health Marketplace enrollment
- ✓ Assistance with Essential Plan and Medicaid applications
- ✓ Year-round support for questions about your coverage
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