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Are you 65+ or Medicare eligible?

Yes No

Financial Assistance Eligibility by Annual Income Level*
Family Size	Annual Income Eligibility for Cost Sharing	Annual Income Eligibility for Tax Credits**
Single person	$16,221 - $29,175	$16,221 - $46,680
Family of two	$21,865 - $39,325	$21,865 - $62,920
Family of three	$27,508 - $49,475	$27,508 - $79,160
Family of four	$33,152 - $59,625	$33,152 - $95,400
Family of five	$38,795 - $69,775	$38,795 - $111,640
Family of six	$44,438 - $79,925	$44,438 - $127,880

If you qualify for financial assistance, you must apply through the NY State of Health.

* Source: 2014 Federal Income Guidelines: Department of Health and Human Services. Full calculator available at http://aspe.hhs.gov/poverty/14poverty.cfm.

**Some individuals and families with household incomes below these limits may qualify for a Premium Tax Credit in certain circumstances where Medicaid is unavailable. See the full calculator for more information.

Please tell us a little more about you

1. Which County do you live in?

2. Do you have and are you planning to keep stand-alone Dental Coverage?

Yes No

3. Who are you looking to cover?

Young Adults Covered through Age 29

If you selected ‘self + children’ or ‘family coverage,’ your young adult child will be eligible for coverage until the end of the month in which he or she turns 30 years of age, when the young adult:

Is unmarried
Is not insured by or eligible for coverage under an employer-sponsored health benefit plan covering him or her as an employee or member, whether insured or self-insured, and
Lives, works or resides in New York State or Our Service Area.

To be covered under this rider, your young adult does NOT need to:

Live with or be financially dependent upon you, nor
Be a student

Get Paid for Working Out

Earn up to $600 each year*

*ExerciseRewards is not available to members of BlueChoice Option, HMOBlue Option, Child Health Plus or Medicare.

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