Healthy Ny Recertification And Plan Selection Form - Oxford Health Plans
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3Healthy NY Recertification and Plan Selection Form
Individual and Sole Proprietor
Mail To: Healthy NY, Attn: Enrollment, 14 Central Park Drive, Hooksett, NH 03106
A. Member Information
Member ID
Name (First, Middle Last)
Phone Number
Address (Where you reside)
City
State
Zip Code
Mailing Address (if different from above)
B. Income Verification (use income chart below to determine eligibility)
Family
Current Monthly Gross Income
Monthly Gross Income Allowed (Based on Family
Size
Size)
Please list the total
Applicant
Spouse
Monthly Household
Family Size
number of members in
Income
your household:
1 person
Up to $2,394*
2
Up to $3,232*
$_________ $________
3
Up to $4,070*
___________
Total Gross Income
4
Up to $4,908*
5
Up to $5,746*
6
Up to $6,584*
$______________
Each additional
Add $838* per person
Household members include you, your spouse (if residing in your household) and dependent children.
Pregnant women count as two people for determining the number of household members.
Income Includes: wages, salary, interest and dividends, self-employment income, social security income,
retirement income, alimony, unemployment benefits and workers compensation. Do not include public
assistance, supplemental security income (SSI), foster care payments or child support received
**Please note: Sole Proprietors may subtract monthly business expenses from their monthly income.**
C. Medicare Eligibility (Persons covered under Medicare will lose eligibility for Healthy NY)
Is anyone to be covered under the policy also eligible for Medicare? _____Yes _____No If yes, please write
the name of the person:________________________________________
D. Plan Selection (Changes only permitted at recertification or at time of a rate change)
Note: HMO Plans are only available to members who presently are enrolled on this plan.
_____
_____
_____
_____
HMO
HMO
High Deductible
High Deductible
(no pharmacy)
(with pharmacy)
(no pharmacy)
(with pharmacy)
High Deductible: The deductible is $1,250* for individuals and $2,500* for families (more than one person).
Except for preventive care, you must pay for the cost of covered services until you meet the deductible. You can
access preventive care before meeting the deductible and may have a co-payment for these services. Co-
payments do not apply towards the deductible. This plan is meant to be used with a health savings account.
Contributions to the health savings account are tax-deductible, and money in the account can earn interest tax-
free. You can contribute up to $3,250* for individual coverage and $6,450* for family coverage into the account
in 2013. Visit for more information.
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