How to shop for health insurance

This is the most money that a health plan will pay for covered health care services. The allowed amount can also be called eligible expense, payment allowance, or negotiated rate. If your provider charges you more than the allowed amount, you may have to pay the difference between the provider’s charge and the allowed amount (this is called balance billing). 

Balance billing is when a provider bills you for the difference between the amount they are charging and the amount your health plan paid. When a provider is in your network, they are not allowed to balance bill you, except for copayment, coinsurance, or deductible. The provider agrees to accept your insurance plan’s payment as payment in full. But a provider that is not in your health plan’s network is allowed to balance bill.

Copayment is a fixed dollar amount. You usually pay a copayment at the time that you receive the service. This amount can vary depending on the type of service you receive. It does not depend on the cost of your medical service. For example: You might pay $25 to visit your primary care doctor’s office, but $50 to see a specialist, $75 to visit an urgent care, and $100 when you go to a hospital.

Coinsurance is a percentage of the cost. For example: Your coinsurance is 20 percent of your health plan’s $150 allowed amount for an office visit. You are responsible for paying $30 (20 percent) and the health plan pays the remaining $120 (80 percent).

Deductible is the amount you must pay for health care services that your health plan covers before your health plan begins to pay. For example: If your deductible is $1,000, your plan will not pay anything until you have paid $1,000 for covered health care services.

The deductible may not apply to all services. For example, some preventive care or maintenance drugs may be excluded from the deductible and will be covered right away.

Deductibles and coinsurance can work together. For example, if you have a deductible of $3,000 and, coinsurance of 20 percent, and the allowed amount for the service is $8,000, then you would pay $3,000 (deductible), then 20 percent of the remaining $5,000, which would be $1,000. Your total out-of-pocket cost would be $4,000 ($3,000 deductible plus your $1,000 coinsurance).

Excluded services are health care services that your health plan does not cover. For example, most health plans do not cover routine dental care.

Network refers to the group of facilities (hospitals, treatment centers, and clinics), providers, and suppliers your health plan has contracted with to provide health care services. Some health plans provide coverage only if you go to in-network providers, with an exception for emergency care services. Other health plans cover both in-network and out-of-network providers, but you pay more to see out-of-network providers.

Out-of-pocket limit or maximum is how much you must pay during a policy period before your health plan begins to pay 100 percent of the allowed amount, and you no longer pay any deductible, copayment, or coinsurance. This limit does not include your premium, balance-billed charges, or health care services that your health plan does not cover.

Premium is the amount that you must pay for your health plan. You or your employer usually pay your premiums per pay period or some other interval, such as monthly, quarterly, or yearly.

Start with the NY State of Health, the official health plan marketplace for New Yorkers. This marketplace helps you find out if you are eligible for tax credits or subsidies that can reduce your costs. You can visit the marketplace website or call toll free:

• NY State of Health website
• 1-855-355-5777 or TTY 1-800-662-1220

Make sure you have the correct web address or phone number. Many websites and call centers intentionally mislead people into thinking that they are the NY State of Health. If you misdial the phone number or go to the wrong website, you could fall victim to a scam.

You must live in New York and be a U.S. citizen, national, or lawfully present immigrant to shop for health insurance at NY State of Health. Different immigration rules may apply if you are eligible for Child Health Plus, Medicaid, or the Essential Plan based on your income.

There are a few items that should go into your selection of the best plan. 

Premiums. Do not just look at the cost of the monthly premium. If you spend less on premiums, you might end up paying more elsewhere. It’s likely that your other out-of-pocket expenses, such as deductibles and copayments, will be higher. 

Metal level. Plans listed on the NY State of Health are rated by metal level: bronze, silver, gold, or platinum. These levels basically describe the breakdown of how much you pay and how much the health plan pays. 

The following chart compares cost breakdowns for various items for each metal level plan purchased through the NY State of Health. This information comes from the federal Health Insurance Marketplace website (February 9, 2026).

Star rating: ACA-compliant health plans receive a quality rating from the federal government. Each health plan on the NY State of Health website is given an overall quality rating of one to five stars (five is the highest quality). Plans are rated for overall quality, as well as for medical care, member experience, and plan administration. Ratings may not be available for plans that are new or have low enrollment. 

See more information about health plan quality ratings on the federal healthcare.gov site.

Consider several factors, including: 

• Are your providers in the plan’s network?
• Does the plan's network include hospitals you might visit?
• Are your prescription drugs covered?
• What are the costs associated with the plan?
  • premiums
  • deductibles
  • copayments for doctor visits, emergency room visits, urgent care visits, physical therapy, prescription drugs, mental health visits
  • coinsurance
• What is the out-of-pocket maximum?
• Are there any perks or extras that come with the health plan? These could include:
  • telemedicine
  • discounts for gyms and other wellness activities
  • health-plan app
  • dental coverage

Your cost for an ACA-compliant health plan will vary depending on several factors, including: 

• where you live in New York
• your income
• the size of your household
• which members of your household you are buying health coverage for

You may be eligible for financial assistance in the form of tax credits if you purchase your health insurance through the NY State of Health. Tax credits can help to reduce your monthly premium costs. 

You still have some options, including:

• Hospital financial-assistance programs are available at all hospitals in New York licensed by the New York State Department of Health. These hospitals are required to establish a financial-assistance program that provides discounts for patients who meet certain requirements. Under state law, hospitals must offer financial aid to you if your income is up to four times the poverty level. But hospitals can offer discounts to patients with higher income levels, and can provide greater discounts than required by law. If you have bills from a hospital, contact the hospital to get information and to apply for financial assistance.
• Discount drug cards can help you save money when purchasing prescription drugs. There are many different discount drug cards available. In these free, non-insurance programs, companies negotiate rates for prescription drugs that are typically lower than retail prices. 
• NYC Care is a health care access program that provides low-cost or no-cost health care to people who live in New York City and who do not qualify for or cannot afford health insurance. All services are offered through NYC Health + Hospitals. 
• Prescription-drug patient-assistance (PAP) programs are offered through drug manufacturers to provide free or discounted prescription medicines. Eligibility requirements vary according to the drug manufacturer and the drug. Pharmaceutical Research and Manufacturers of America (PhRMA), a trade association for the pharmaceutical industry, provides a free Medicine Assistance Tool (MAT) for patients to search to see if you are eligible for a PAP to help with the cost of your prescription medications. You can also contact your prescription-drug manufacturer directly to see if you qualify for their PAP.
• Elderly Pharmaceutical Insurance Coverage (EPIC) program is a New York state program for seniors, administered by the New York State Department of Health. It helps income-eligible people aged 65 and older to supplement their out-of-pocket costs under Medicare Part D drug plans. 
• Medicare Part D Extra Help assists with the cost of prescription drugs, like copayments and deductibles for Medicare Part D.
• AIDS Drug Assistance Program (ADAP) and related programs are offered through the New York state Department of Health to provide access to free health care for New York State residents living with or at risk of acquiring HIV or AIDS. Items covered by this program include drugs, outpatient primary care, home care, insurance premium payments, and pre-exposure prophylaxis to prevent HIV infection.

If you are buying health insurance outside of the NY State of Health marketplace, be very careful! Government websites like the NY State of Health will have “.gov” as part of the website’s internet address. 

Many websites promise affordable, high-quality health insurance. Some websites even look like the NY State of Health website or seem as though you will be buying a health plan from a government-approved website. 

But, instead of an ACA-compliant health plan that provides comprehensive health coverage, you could get something that is much more limited. You could end up liable for medical expenses that you thought would be covered. 

If a health plan does not comply with the ACA, it does not have to cover the 10 essential health benefits that ACA-compliant plans do, like prescription drugs, emergency services, lab services, hospital service, and mental health and substance-use-disorder services.

Examples of health plans and products that do not comply with the ACA include:

• Indemnity plans are health plans that pay a predetermined amount either for each health care service (for example, $50 for each doctor visit or $100 per day for a hospital visit) or for a period of time (for example, $5,000 per year for hospital visits). In addition to limiting how they pay for health care services, these plans do not cover pre-existing conditions. They also have limits on annual or lifetime benefits (for example, a limit of five hospital visits per year).  
• Discount benefit plans are not health insurance. These plans offer you access to a network of providers who agree to accept a discounted rate for their services. You are responsible for paying providers their discounted rates when you receive services. You pay a monthly fee, often less than $100 per month, to be part of these discount plans. In addition to discounts for medical providers, these plans may also provide discounts for dental, vision, prescription drugs, and other health services. Remember: These plans do not provide health coverage. A serious health condition or hospitalization could leave you responsible for thousands of dollars in medical expenses. These plans do not cover these costs.
• Discount drug cards, used as standalone products, can offer you savings compared to retail prices for prescription drugs. But beware of discount drug cards that are paired with plans that do not provide comprehensive health coverage, such as indemnity plans, discount benefit plans, and health care sharing ministries. Companies pair these items to give the impression that they are offering a comprehensive set of benefits.   
• Health care sharing ministries or sharing plans are organizations of people who share similar religious or ethical benefits. These organizations pool money to pay for the health care expenses of their members. These plans do not guarantee how much they will cover for submitted claims. In addition, they typically exclude coverage for reproductive medicine, such as birth control and abortions, and services for mental health and substance-abuse treatment.  
• Short-term health insurance is health insurance that offers temporary coverage for a limited period of time. These plans are not required to cover mental health, substance-abuse treatment, maternity care, or prescription drugs. In addition, they often do not cover pre-existing conditions. Short-term health insurance is prohibited in New York.

If you are shopping for health insurance outside the NY State of Health marketplace, and find health coverage that sounds too good to be true, it probably is. To get you to enroll in a plan, scammers will mislead you and tell you things that are not true about the health plan they are trying to sell you.

Watch out for these warning signs that someone may be trying to mislead you into buying a plan that does not provide comprehensive benefits, is not health insurance, or does not meet your needs:

• The seller cannot answer basic questions about the product they are selling.
• The seller pressures you to buy the product right away. They say that they cannot guarantee the price if you buy it later. They may even become verbally abusive to get you to buy the product.
• The seller may tell you that your doctors and hospitals are covered under the plan, without explaining what that specific coverage is or whether the coverage is in or out of network. The salesperson will often say that the medical providers “take” the product ─ which does not mean that the medical providers have an in-network contract with that plan.
• The product being sold to you is much cheaper than what other companies have offered. 
• The seller will not give you plan materials in writing before you purchase the product. They may even say that they are not allowed to provide you with plan materials unless you first give them your personal information, such as your bank account number or your Social Security number. 
• Pay careful attention to the name of the plan. Sometimes scammers will tell you about a plan’s provider network, giving the impression that the provider network is actually the health plan. The provider network is not the same as the insurer or the entity that is responsible for paying for your health care services. Examples of provider networks that are often mentioned by scammers to mislead you include First Health and Multiplan. Also pay attention to whether the scammer tells you that a plan is affiliated with an actual insurance company, such as Aetna or BlueCross BlueShield. Sometimes major insurance companies will have subsidiaries who are not actually insurers. 
• Beware of anyone who contacts you to talk about health insurance if you did not contact them first. 
• Be careful if a contact person gives you vague statements, such as that they “work with the Exchange” or they “are affiliated with the Exchange.”

If the plan is described as a health insurance plan, try the following:

• Ask the New York State Department of Financial Services if the plan is a legitimate health insurance plan that is licensed in New York, or use the Department of Financial Services’ Insurance Company Search to see if the plan is licensed in New York. 
• Check with the Better Business Bureau (BBB) for complaints about the company.
• See if other people have reported concerns about the health plan in online reviews or discussion threads.

Contact the Health Care Helpline at the Office of the New York Attorney General by phone or online:

• Call the helpline at 1-800-428-9071.
• File an online complaint.