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Have questions about
claims or our network?

Our automated phone system is available:
24 hours a day 7 days a week

Live Phone Representatives are available:
9:00 am to 5:00 pm

New York Claims Submission Address:
P.O Box 958438
Lake Mary, FL 32795

New York Request for Review and Reconsideration:
P.O Box 958438
Lake Mary, FL 32795

Electronic Payor ID: 80141

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Understand What Health Care Reform Means to You and Your Patients

The federal Affordable Care Act (ACA), also known as “Health Care Reform,” establishes competitive health insurance “Exchanges,” or online marketplaces, so that individuals and small businesses can more easily navigate the healthcare system.

An Exchange is designed to be a "one-stop shopping" option for consumers to purchase health insurance. The Exchange will help consumers calculate costs, compare health plan options, and check to see if they’re eligible for public programs such as Medicaid and Child Health Plus.

Learn more about Health Care Reform and the Exchange by exploring the Frequently Asked Questions below.

Health Care Reform Provider Questions

Will Healthfirst participate in New York’s health care “exchange” or “marketplace”?

Yes, Healthfirst intends to participate in the Individual Health Exchange in 2014, pending approval of plans submitted to the New York State Department of Financial Services.

Under the Affordable Care Act, who will be required to obtain health insurance?

Starting in 2014, under Federal law, every United States citizen will be required to obtain health insurance (with very few exceptions). Those without insurance will face financial penalties equating to a percentage of the person’s annual income. The penalty in 2014 will start at 1% of one’s salary or $95 (whichever is higher), and will increase every year until 2018.

Here’s a snapshot of what the penalties for not having health insurance will be with ACA:

  • 2014:  $95 (individual), $285 (household cap) or 1% of income, whichever is greater
  • 2015:  $325 (individual), $975 (household cap) or 2% of income, whichever is greater
  • 2016:  $695 (individual), $2,085 (household cap) or 2.5% of income, whichever is greater

What types of health care “exchanges” or “marketplaces” will be in New York?

There will be two types of Exchanges in New York:

  • Individual Health Exchange – for individual consumers
  • SHOP Health Exchange – for small businesses (2-50 employees)

Note:  New York State plans to release the official name soon.

What type of products will be available on the New York Health Benefit Exchange (name to change)?

There will be various types of Exchange products in New York: 

  1. Commercial plans, also called Qualified Health Plans (QHPs)
  2. Public options– Child Health Plus and Medicaid*

* Family Health Plus members will become qualified for either Medicaid or a QHP depending on their Adjusted Gross Income.

Who is eligible to enroll into commercial insurance plans on New York’s “exchange” or “marketplace?”

There are income limitations to enroll into a QHP product. One can purchase a QHP product as long as they:

  • Live in New York State
  • Are between the ages of 18 and 64 (or above 64 and not eligible for Medicare)
    • Enrolling subscribers can opt to cover dependent family members from birth through age 29 under their policies depending on the level of coverage they enroll in.
  • Currently not eligible for a public option
  • Are a legal citizen or resident
  • Have household income greater than 138% of the Federal Poverty Level (in 2013, $32,499 for a family of four)
  • Are a small business with 2–50 employees

Nearly 2.7 million New Yorkers under age 65, about 16%, do not have health insurance coverage. The majority of the uninsured are workers and their families. As many as 1.2 million New Yorkers are projected to become newly insured once Health Care Reform takes full effect.

You can download a full set of FAQs by signing in to the Provider Portal here.


*This information should be used as a guide and is subject to change based on rules and regulations released from the New York State Department of Financial Services and the United States Department of Health and Human Services. For the most up to date information, please refer to or