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Off Exchange Indiv Enroll


We're sorry, but we were unable to complete your request at this time.
If you need assistance, please visit our Contact Us page for a listing of telephone numbers.
 
We apologize for any inconvenience this may have caused. 11/19/2019 T16:43:36-0500
 

Enroll in

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About you
Coverage

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.

We have provided you with coverage of the pediatric dental essential health benefit at an additional charge.
When you can enroll outside of Open Enrollment

Are you losing coverage from Univera Healthcare?*

If your event date is outside of 60 days from today's date, you must wait for Open Enrollment
Event Date must be Date of Death of deceased
Event Date must be newborn's Date of Birth
Date Pregnancy Confirmed
The date you request may change based
on the reason you are applying
A copy of Proof of loss of coverage is required before we can complete this request.
LIST OF ACCEPTABLE PROOF: Proof of loss of coverage from previous employer (term letter, pay stub of both current and previous hours, letter from employer staying no longer eligible, legal document from current health insurance plan (including exchange) advising termination date and reason to be involuntary, insurer termination notice/letter.)
A copy of D29 Annual Certification form is required before we can complete this request.
A copy of your Marriage Certificate or Proof of Domestic Partnership and Financial Interdependence is required before we can complete this request. NOTE: Date on the proof must match the event date indicated.
Please attach proof that one spouse had Minimum Essential Coverage or that they lived outside of the US or in a US territory for one or more days during the 60 days preceding the date of marriage
A copy of Death Certificate or Obituary, Proof of loss of coverage listing who was covered under old policy is required before we can complete this request.
A copy of the Birth Certificate is required before we can complete this request.
A copy of the Adoption Certificate, Proof of Custody or Proof Adoption petition is filed is required before we can complete this request.
A copy of Adoption Certificate, Proof Adoption petition is filed or Court Documents appointing Legal Guardianship is required before we can complete this request.
A copy of address change is required before we can complete this request.
LIST OF ACCEPTABLE PROOF:
  • Proof of residency (e.g. prior and current utility bill, phone bill, lease agreement etc. in applicant's name) within 60 days.
  • Proof of prior coverage OR proof that no Qualified Health Plan (QHP) options were available in the prior county must be attached.
A copy of Divorce Certificate, Divorce Decree, Annulment Court Ruling, Legal Separation Agreement or affidavit of Domestic Partnership discontinuance is required before we can complete this request.
A copy of the Confirmation of Pregnancy form or equivalent form is required before we can complete this request.
LIST OF ACCEPTABLE PROOF: The pregnancy should be documented and verified by the Provider on the Confirmation of Pregnancy form or equivalent form or letterhead signed by confirming Dr with date pregnancy confirmed.
A copy of proof of release from incarceration is required before we can complete this request.
A copy of proof of becoming a Citizen, National or Lawfully present is required before we can complete this request.
A copy of proof of court order is required before we can complete this request.
A copy of economic hardship-HHS Certificate of Exemption is required before we can complete this request
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Subscriber

You selected a 'Child-Only' plan. Please enter the youngest child as the Subscriber.

Address

Home Address

Mailing Address

Family Member(s)

To enroll family members, click the below button.

 Add Family Member

Use the 'Edit' or 'Remove' buttons to make changes to family members

Select Name Relationship Date of Birth
 Edit Family Member     Delete Family Member

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.

A copy of Disability Certificate is required before we can complete this request
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*

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?*

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.

Does the dependent live, work or reside in New York state?*

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.

NOTE: We are required to ask for your Social Security Number in order to meet reporting obligations under the Affordable Care Act

Third Party Administrators

Has a Broker Agent , Sales Representative or Marketplace Facilitated Enroller (MFE) helped you to complete the application?

Enroll in Summary

The Health Plan you selected is not available in the area where you live. Please see the field highlighted in Red below.

  • If your Zip code is wrong, please select 'Edit' to correct it, or
  • If your Zip code was entered correctly, you will need to select a different plan by returning to our Plan Comparison Tool.

Your application has either missing or incorrect information so we cannot accept it electronically.

  • See the field(s) highlighted in Red below and select 'Edit' to update the information

 Please review your information (use 'Edit' to make any changes) and select 'Submit' to send us your information

Coverage
Reason for Enrollment:
 
Event Date:
 
Requested Effective Date:
 
Documentation:
     
Subscriber
First Name:
 
Middle Initial:
 
Last Name:
 
Title:
 
Gender:
 
Date of Birth:
 
Social Security Number:
 
Address
Home Address
Street Address:
 
 
 
Email Address:
 
State:
New york
Zip:
 
City:
 
Daytime Phone Number:
 
Mailing Address
In Care of:
 
Street Address:
 
 
 
Email Address:
 
State:
 
Zip:
 
City:
 
Day-time Phone Number:
 
Family Member(s)

No Family Member has been entered

Dental Coverage
Please provide the name of the company issuing the stand-alone dental coverage:  
Legal Acceptance
*
Third Party Administrators

No Third Party Administrator has been entered

Name of Broker/Agent/CAC/Person Assisting
 
Agency Name (if Applicable)
 
Agency License # (if Applicable)
 
Agency TaxID (if Applicable)
 
Please Confirm

Are you sure want to proceed without adding a family member?

Please Confirm Family Members

You selected a plan, Are you sure want to proceed without adding a family member?