Affinity Health Plan

  • 2017 QHP Banner 3
  • Frequently Asked Questions about Using Your Coverage Starting January 1, 2017

    Now that you’ve enrolled in one of Affinity's plans through the NY State of Health, you may have some questions about how to use your coverage. See below for answers to some frequently asked questions. If you have a question that is not answered below, call our Customer Service department at 888.543.6973.

     

    Using Your Coverage

    Will I be covered for health care services I receive on or after January 1st if I haven’t received my health plan identification (ID) card yet?
    Yes. Affinity will cover services you use starting January 1, 2017, as long as you pay your premium by January 10th. If your effective date is in February, you have until the 10th of that month to pay your first premium to become a paid member. Your health care provider can check with your insurer about your coverage. Providers can call health plans to confirm that you are enrolled in a Marketplace health plan.

    You can review Affinity's provider network.

    How can I pay my premium bill for January 1st coverage?
    You need to pay Affinity – not NY State of Health – no later than January 10th, or the 10th day of the month if your effective date starts in a later month.. You can pay the bill by mail, over the phone or online. Contact us for payment options or if the due date is a problem for you.

    When will I get membership ID cards?
    We will mail you an enrollment package and membership ID card within 7 to 10 business days of receiving your premium payment.

    I thought I bought a health plan, but Affinity doesn’t have a record of my enrollment. What should I do?
    Call the NY State of Health Customer Service Center at 855.355.5777. A trained representative can assist you. If you enrolled with an Affinity Marketplace Facilitated Enroller (MFE), you may contact your MFE for help first. If there was a problem with the Marketplace systems that prevented you from getting coverage even though you tried to enroll before December 31, you may be eligible to get coverage as soon as possible.

     

    Providers

    How can my health care provider confirm that I am enrolled in a Marketplace health plan?
    Providers can visit the Affinity Provider Portal at https://affinityny-portals.ikaenterprise.com/Provider/Providers.aspx or call Affinity Customer Service at 888.543.6973 to confirm Marketplace enrollment of their patients.

    If your provider cannot confirm your enrollment, you may have to agree to pay for the services and submit a claim to your health plan for payment after you get your care. The address for paper claims is:

    Affinity Health Plan
    Attention: Claims Unit
    P.O. Box 981650
    El Paso, TX 79998-1650

    It is likely that by the time you get a bill from your provider, you will already be entered into Affinity’s system. You should call your provider and have them submit their bill directly to AffinityAccess claims. Call Customer Service at 888.543.6973, if you have questions about whether a service is covered or about how to use your coverage.

    How can I find out if health care providers - my doctor, hospital, or medical group or clinic - are in my new NY State of Health plan?
    To find out if your doctors and other health care providers are included in your Affinity plan or to find a participating provider if you don’t have one yet you can:

    • Affinity's provider directory, is a list of the doctors, hospitals, and other health care providers that Affinity contracts with to provide care.
    • Call us at 888.543.6973 to ask about specific providers. We will have the most up to date information about which providers are in our network.
    • Call your doctor’s office. They can tell you if they accept Affinity Health Plan.

    My new health plan doesn’t include my doctor in the provider network, but I am getting treatment for a serious condition. What should I do?
    Call us at 888.543.6973 to let us know about your treatment. Your treatment may be covered for a transition period after you change plans if you are in the middle of a course of treatment for a serious condition (life-threatening, degenerative, disabling, or if you have entered the second month of pregnancy). Call your provider, let them know your insurance is changing and ask them to work with Affinity to determine appropriate coverage of your treatment.

    I’ve already enrolled in a Marketplace plan, and I just found out that my doctor isn’t in my plan’s provider network. Is there anything I can do?
    If you’re already enrolled in a Marketplace plan, you can switch to another Marketplace plan during Open Enrollment, which ends on January 31, 2017, or to another plan offered outside the Marketplace. If you decide to switch plans, ask your doctor which health plans they work with.

    If you’re eligible for a tax credit, you’ll be able to apply your tax credit to the new plan’s premium to lower your costs. You can only apply the tax credit toward plans you buy through the Marketplace.

    You’ll want to find out when your new coverage will start before you cancel your current plan so you don’t have a gap in coverage. After January 31, 2017, you will not be able to change your plan until the next open enrollment period.

    Does my new insurance plan cover my prescription medication?
    Affinity will cover some or all of the cost of certain prescription medications. Medications on your plan’s “formulary” (approved list of covered medications) usually will cost you less than medications that are not on the formulary. To find out which prescriptions are covered through Affinity Health Plan you can:

    • Visit our Pharmacy Benefits page.
    • Benefit Summaries are available here.
    • Call CVS Customer Service at 855.722.6228 to find out what is covered.
    • Review any coverage materials that we mailed to you.
    • Note that prescription drugs for all Platinum, Gold, and Silver plans are not subject to the deductible.

    I’m at the pharmacy to pick up my prescription, and they said my plan no longer covers it. What do I do?
    A one-time refill for your medication after you first enroll may be allowed. Please call Customer Service at 888.543.6973 and select the prescription drug option to find out. If you can’t get a one-time refill, you have the right to follow a drug exceptions process that may allow you to get a prescribed drug that’s not normally covered.

    Affinity denied my request for an exception. Can I appeal?
    If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights or for assistance you can contact:

    Affinity Health Plan
    Quality Management Department
    Complaint, Grievance & Appeal Unit
    Metro Center Atrium
    1776 Eastchester Road
    Bronx, NY 10461
    Tel: 888.543.9069
    Fax: 718.543.9069

    Can I go to my regular pharmacy to get my medication?
    Affinity’s in-network pharmacies include all the major chains like CVS, Duane Reade, Walgreens, and Rite Aid. You may get your prescription drugs at a retail pharmacy or by mail order.

     

    Emergency Care

    Can I go to any hospital or urgent care center for emergency services?
    If you believe you have an emergency condition you may go to any hospital emergency room or urgent care center, and they will treat you even if you don’t have health insurance. In an emergency, you do not need prior approval before getting emergency services. However, you should report any emergency visits or admissions within 24 hours by calling 888.543.9074 (this number can also be found on the back of your ID card).