(518) 792-3537 Queensbury • (518) 584-8202 Ballston Spa SAIL@SAILhelps.org

Health

Health Insurance Enrollment and Help

If you need health insurance or have health insurance questions or problems, SAIL can help! SAIL is excited to continue offering a variety of health insurance services in the communities around us and even stretching to counties north and west of our physical locations. These services can help someone from the moment they find out they are pregnant to that time when they are planning for end of life care. This approach of having a variety of services that can help people through all aspects of health insurance needs allows us to be there for you as your needs change and when you have questions or problems in the future with your health insurance or health related needs.

SAIL Navigators Serve:

  • Clinton County, NY
  • Essex County, NY
  • Hamilton County, NY
  • Warren County, NY
  • Washington County, NY

SAIL Navigators:

Help people apply for insurance on the New York State Health Benefits Exchange, often referred to as the Marketplace.

Services:

SAIL Navigators will help you research and apply for insurance options on the Marketplace including Child Health Plus, low income Medicaid, Essential Plans and Qualified Health Plans.

Facilitated Enrollers (FEs) Serve:

  • Fulton County, NY
  • Hamilton County, NY
  • Montgomery County, NY
  • Warren County, NY
  • Washington County, NY

Facilitated Enrollers:

Are health insurance enrollment specialists who help people apply for Community Based Medicaid, Medicare Savings Plan and Medicare by guiding them through the application process, from start to finish.

Services:

The Facilitated Enrollment program is for individuals who are aging (over 65), blind or have significant disabilities (ABD). They provide Medicaid enrollment assistance, assistance paying for Medicare through the Medicare Savings Program, and education on options for meeting the Medicaid spend down for those in the excess income program.

Community Health Advocates Serve:

  • Clinton County, NY
  • Essex County, NY
  • Franklin County, NY
  • Fulton County, NY
  • Hamilton County, NY
  • Montgomery County, NY
  • Saratoga County, NY
  • Warren County, NY
  • Washington County, NY

Community Health Advocates (CHA):

Help if you have questions about your coverage, need to appeal to get something covered, or just need someone to look up your prescriptions or help you find a doctor on your plan.

Services:

SAIL’s CHA program can help you enroll in Medicare Advantage Plans, has people that help you look up free or reduced cost prescriptions from Pharmaceutical company programs to afford medications, help you find coupons for your prescriptions, or even look up where your prescription is less expensive to purchase. The CHA program can also help you apply for discounts on your medical care through patient assistance applications and help you find programs to assist in covering the costs of medical care if you don’t have access to health insurance.

Let SAIL Help You Get Covered!

Enrollment in Medicare or Supplemental Plans

SAIL’s staff can offer assistance reviewing options for additional coverage to supplement original Medicare as available based on County. These plans have a number of options, formularies, networks, and costs based on the location and plan selected. The SAIL staff will help you navigate through the various costs and options to help you decide what is best for you in your situation. This help is available during Open Enrollment from October 15 to December 7 each year. However, SAIL staff are available all year round to help with Special Enrollment Periods and other challenges and issues that come up during the year.

Health Insurance Advocacy
  • Advocacy for Long-Term-Care Services through Medicaid
  • Technical assistance preparing for Plan Appeals and Fair Hearings related to service terminations and decreases
  • Assistance addressing authorization denials from all insurance types
  • Advocacy with eligibility determinations from NYS of Health Marketplace
  • Assist with filing of complaints to Department of Health against plans, providers, and facilities
Medicaid

There are many types of Medicaid. They are all based on income, but the income levels change based on your age and circumstances.

SAIL helps people navigate what application and recertification process they should use and what programs they may be eligible for based on their household income, size, and needs. For people who have long term care needs, they may want to have their “excess income” be considered as a “spenddown” so that they can become Medicaid eligible due to the high costs of long term care services. There are also high Medicaid limits for people who are pregnant, infants and children. Some cancers and other conditions can also influence if you are eligible for Medicaid. Last but not least, if you are a person with a disability who is working you MAY BE ELIGIBLE FOR MEDICAID at a higher income level due to your status!

If you have ANY questions call or come by SAIL to find out what you may be eligible for.

Child Health Plus

Child Health Plus is Health Insurance Program for children up to age 19. SAIL Navigators can assist with applying and renewing coverage through the NYS of Health Marketplace. This is a great insurance program that covers most needs with no copays after the sliding scale premium costs and is widely accepted. This can be a very affordable plan for families, even free for some, with children and there is no maximum income for eligibility. If you are “over income” for the sliding scale then you just pay full cost for that plan premium and receive all the benefits of the Child Health Plus plan once the premium is paid. There may be a 3 month waiting period in some cases, ask a Navigator if you qualify for that requirement.

Essential Plan

The Essential Plan is a health plan for adults age 19-64 and SAIL staff can help assist you in applying for this plan if you are income eligible through the NYS of Health Marketplace. This is a very affordable plan ($0 or $20) for those who are income eligible. The day-to-day costs are also very reasonable and affordable compared to many more expensive plans. You can find out if you are eligible by submitting an application through the NYS of Health Marketplace with a Navigator.

Qualified Health Plan

SAIL staff can also help you apply for a plan you pay the premium for through the NYS of Health Marketplace. These plans are called Qualified Health Plans (QHP’s). Through the Marketplace, people can learn what financial assistance is available to them and what health insurance options they qualify for, based on their income and other factors. Two common types of financial assistance people might receive through the Marketplace are Advance Payments of the Premium Tax Credit (APTC) and Cost-Sharing Reductions (CSRs). APTCs are savings on the premium given on a month-by-month basis through the Federal Government and reported and reconciled on your taxes. The CSRs are day to day savings based on your income that may make lower cost plans more affordable for people who may not be able to afford the higher cost plans. You can find out what you are eligible by meeting with a Navigator. And applying through nystateofhealth.ny.org.

Advocacy for Long Term Medicaid

ICAN Advocates provide assistance to individuals accessing Long Term Care Services and Supports through Managed Medicaid Plans (Managed Long Term Care and Mainstream Managed Care) at all points along the application and enrollment process. This includes advocacy with Local Department of Social Services, Maximus and directly with the care plan to help people maintain, increase or access available services.

SAIL Advocates:

  • Provide information on Home Care options available to individuals who wish to live at home
  • Assist with completion of Non-MAGI (not eligible under the NYS of Health Marketplace because the individual has Medicare, a significant disability, is over sixty-five, or is blind) Medicaid applications in order to access services
  • Assist individuals to obtain the services they need to return home from Nursing Homes
  • Assist individuals with requesting new or increased services
  • Provide technical assistance when appealing plan decisions
  • Provide technical assistance when filing complaints with NYS Department of Health

ICAN is the New York State Ombudsprogram for people with Medicaid who need long term care or behavioral health services. 

Services of the ICAN program include:

  • Private, one-on-one counseling about health insurance options through:
    • Our toll-free telephone helpline – (844) 614-8800
    • In-person appointments at one of our meeting sites around New York state
    • In-person appointments at your home, if you have difficulty traveling or communicating by phone
  • Educational sessions for consumers and caregivers
  • Professional training for social services organizations
  • Educational material

ICAN’s services are free and confidential.

ICAN is a program of Community Service Society of New York, a non-profit organization in New York City, and is funded by the State of New York.

Special Enrollment Periods

Special Enrollment Periods are times where you can apply for health insurance outside of the normal open enrollment periods. This is helpful when there is a change in your life and you can no longer afford or are no longer eligible for your previous health insurance coverage. The things that may qualify you for a Special Enrollment Period are changes in your life like having your family size change, changes in where you live, or changes in your household’s income. SAIL staff can help you not only when you need to enroll or renew in a plan, but also when you need to change your coverage during the year and you may be eligible for a Special Enrollment Period.

There are different rules for the NYS of Health Marketplace than for Medicare. A list of current Special Enrollment Period triggering events are listed below for both the Marketplace and for Medicare.

For NY State of Health Marketplace:

You need to apply within 60 days before or after the event occurrence date.

  • Moving between counties
  • Moving into NYS
  • Having a change in household size due to birth, death, marriage, divorce, or adoption
  • Loss of minimum essential coverage through employer or due to change in program eligibility
  • Change in immigration/citizenship status
  • Becoming pregnant
For Medicare:
  • You have creditable drug coverage or lose creditable coverage through no fault of your own
  • You choose to change employer/union coverage (through either current or past employment)
  • You are institutionalized
  • You are enrolled in a State Pharmaceutical Assistance Program (SPAP)
  • You have Extra Help, Medicaid, or a Medicare Savings Program (MSP)
  • You gain, lose, or have a change in your Medicaid, MSP, or Extra Help eligibility status
  • You want to disenroll from your first Medicare Advantage Plan
  • You enroll in/disenroll from PACE (Program of All-Inclusive Care for the Elderly)
  • You move (permanently change your home address)
  • You have had Medicare eligibility issues
  • You are eligible for a Special Needs Plan (SNP) or lose eligibility for your SNP
  • You are passively enrolled into a Part D plan or Dual-eligible SNP (D-SNP)
  • You experience contract violations or enrollment errors
  • Your plan no longer offers coverage
  • You disenroll from your Medicare Advantage Plan during the Medicare Advantage Open Enrollment Period
  • You qualify for a new Part D Initial Enrollment Period when you turn 65
  • You want to enroll in a five-star Medicare Advantage Plan or Part D plan
  • You have been in a consistently low-performing Medicare Advantage or Part D plan
  • Your Medicare Advantage Plan terminates a significant amount of its network providers
  • You experience an “exceptional circumstance”

SAIL helps you turn problems, needs, and fears into YOUR stories of success.