As part of the Affordable Care Act (ACA), North Shore-LIJ Insurance Company Inc, one of New York’s newly admitted insurer’s, has released their individual and SHOP exchange rates for the downstate NY area.

What’s unique about the “CareConnect” set of LIJ health plans is that while they are EPO-based, the plans are only accepted by the North Shore-LIJ network of doctors, hospitals, and clinics. There is no wrap-around network (e.g. Oxford EPO -> United HealthCare), and there is no out of network coverage except for emergencies. LIJ will be writing plans both on and off the NY health insurance marketplace.

Plan Types

ACA-compliant, on-exchange, LIJ plans will include all metal grade options, as well as a catastrophic-only option. To qualify for a catastrophic plan, an individual must be under 30 years of age or have obtained a certificate of exemption per the individual mandate based on ACA regulations.

For standard plan designs, after the deductible is met, a co-pay or coinsurance figure is applied to the remainder of the allowed amount until the maximum out-of-pocket limit is reached.

Plan Prices

ACA-compliant, on-exchange, LIJ plan prices will vary depending on metal grade and the number of dependents you wish to enroll in coverage. This holds true for all standard individual exchange plans, as well as both standard and non-standard plans for small groups via the SHOP exchange. LIJ rate cards for individuals and small businesses can be found below:

LIJ – Individual Rate Card
LIJ – Small Group Rate Card

The LIJ Network

North Shore-LIJ CareConnect’s plans feature in-network access to 16 hospitals, over 7,000 participating providers and more than 400 ambulatory and ancillary sites.

Pharmacy Network

Members will be able to fill prescriptions at any CVS/Caremark location.


New York State of Health (on-exchange) plans will be offered in Nassau, Queens, Richmond, and Suffolk counties. Off-exchange plans will also include New York County.


Individual Plans will be available on October 1, 2013, with an effective date of January 1, 2014. Individuals must reside within Nassau, New York, Queens, Richmond or Suffolk counties to be eligible for coverage.

Licensed Broker Assistance

Due to a delay by the New York State Department of Financial Services, it is anticipated that licensed, NYS insurance producers will be able to provide support and individual exchange plan recommendations to health insurance consumers sometime in October 2013. With plenty of time to enroll in coverage (effective date of January 1 2014), consumers who do not wish to work with unlicensed/non-background-checked “navigators” are encouraged to wait until the NYS DFS officially approves producer support for individual products. As a reminder, unlicensed exchange “navigators” are not permitted to make plan recommendations for insurance consumers.

Stay tuned for more information regarding the launch of the NY State of Health exchange marketplace…