Are you 65+ or Medicare eligible?*
If you have Medicare coverage, you cannot enroll in this plan. However, you can enroll other family members who aren't eligible for Medicare. Change your answer above to "No" to continue enrolling other family members, or follow this link to View Our Medicare Plans.
Do you have and are you planning to keep medical coverage with another insurer (other than Medicaid)?*
You cannot be the Subscriber/Policy holder on the selected plan, however you can enroll other family members and Subscriber/Policy holder who do not have other medical coverage. Change your answer above to "No" to continue enrolling other family members.
Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a NY State of Health-certified stand-alone dental plan offered outside of the NY State of Health?*
Your selected plan includes pediatric dental coverage benefit at an additional cost. Please either revise your answer here or Select a New Plan and answer 'Yes' on the stand-alone dental coverage question.
Your selected plan does NOT include pediatric dental coverage. Please either revise your answer here or Select a New Plan and answer 'No' on the stand-alone dental coverage question.
Are you losing coverage from an Excellus BlueCross BlueShield Plan?*
You selected a 'Child-Only' plan. Please enter the youngest child as the Subscriber.
Is the Mailing Address same as the Home Address?*
To enroll family members, click the below button.
Use the 'Edit' or 'Remove' buttons to make changes to family members
Is family member 65+ or Medicare eligible?*
This family member cannot be added to the plan, however you can enroll other family members who do not have Medicare Coverage. Change your answer above to 'No' to continue enrolling other family members.
Does the family member have coverage from another insurance carrier(other than Medicaid)?*
Family member cannot be added to the selected plan, however you can enroll other Family members who do not have Other Medical Coverage. Change your answer above to "No" to continue enrolling other family members.
Please answer below questions
Is the dependent unmarried?*
We're sorry, the plan you selected does not cover dependents age 26 to 30 (up to their 30th birthday) who are married or eligible for other coverage or live, work, reside outside New York. If you answered the questions above incorrectly then change your answers to "Yes" to continue enrolling the family member, or follow this link to Select a New Plan.
Is the dependent under 30 and not insured by or eligible for employer sponsored health benefit plan?*
Does the dependent live, work or reside in New York state?*
NOTE: We are required to ask for your Social Security Number in order to meet reporting obligations under the Affordable Care Act
Pursuant to federal rules that implement the Affordable Care Act, individual health insurance policies must be written on a calendar year basis. This means that if your requested effective date of coverage is a date later than January 1 of a year, the initial term of coverage for your policy will be for less than a full year and will end on December 31 of the same year. Please be advised that all benefits and cost sharing under your policy, including the full annual deductible, apply to the partial year of coverage.
I acknowledge and agree that by signing this enrollment form and subsequently accepting services, I and everyone else who is covered under the contract you issue is bound by the terms and conditions of the contract applicable to my coverage. This includes, without limitation, the terms and conditions regarding the receipt and release of medical records and information. I make this acknowledgement and agreement on behalf of myself and each other person who accepts coverage under the terms of the contract applicable to my coverage (who may include, for example my spouse and my eligible family dependents).
I hereby accept responsibility for payment of any portion of the premium. I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge.
I understand that if I elect Exclusive Provider Organization (EPO) coverage, except in an emergency, all care must be provided by medical providers who participate with the EPO and I will not receive benefits for care that I receive from providers who do not participate with the EPO.
I have thoroughly read, understand and agree to comply with the terms of the release on the back.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
Has a Broker Agent , Sales Representative or Marketplace
Facilitated Enroller (MFE) helped you to complete the
The Health Plan you selected is not available in the area where you live. Please see the field highlighted in Red below.
Your application has either missing or incorrect information so we cannot accept it electronically.
Please review your information (use 'Edit' to make any changes) and select 'Submit' to send us your information
No Family Member has been entered
No Third Party Administrator has been entered
Are you sure want to proceed without adding a family member?
You selected a plan, Are you sure want to proceed without adding a family member?