PLAN NAME & PURPOSE
Gig Insure is a fully Health Plan designed for gig workers, freelancers, self-employed individuals, and contract earners in New York.
This plan integrates:
- •Pre-Pay Wallet Funding (Required)
- •Rewards-Based Premium Credits
- •Comprehensive Essential Health Benefits (EHB)
- •Zero-Broker Distribution
- •AI-Assisted Claims + Underwriting
- •Full ACA Compliance
ESSENTIAL HEALTH BENEFITS
Ambulatory Patient Services
Primary care, specialist visits, diagnostic services.
Emergency Services
ER visits covered with no prior authorization required.
Hospitalization
Inpatient care, surgery, ICU, inpatient medications.
Maternity & Newborn Care
Prenatal visits, delivery, postnatal care.
Mental Health & Substance Use Disorder Services
Tele-therapy + in-person therapy & inpatient treatment.
Prescription Drugs
Formulary with preferred generics, brand, specialty tiers.
Rehabilitative/Habilitative Services
Physical therapy, occupational therapy, speech therapy.
Laboratory Services
Diagnostic labs, imaging, pathology.
Preventive & Wellness Services
100% covered with no cost-sharing.
Pediatric Services
Including vision and dental.
PLAN – COST STRUCTURE (NEW YORK)
Monthly Premium:
Variable, based on wallet balance + rewards tier.
Base Rate (NY):$412/month→ reducible up to 20%
| Cost Component | Individual | Family |
|---|---|---|
| Pre-Pay Wallet Required Minimum | 💳$200 deposit to activate coverage | |
| Deductible | $2,800 | $5,600 |
| Out-of-Pocket Maximum (OOP) | $9,200 | $18,400 |
| Coinsurance | 20% after deductible (standard Silver plan structure) | |
💵Co-pays:
PCP Visit
$25
Specialist
$40
Mental Health Telehealth
$0–$15
Generic Prescriptions
$5
Preferred Brand
$25
Emergency Room
$250
REWARDS & WALLET TIERS (NY REGULATED VERSION)
Because NY prohibits unlawful premium rebates, Gig Insure adopts a credit-based system compliant with DFS rules.
Tier 1 – Silver
$100–$199
- ✓5% annual premium credit
- ✓5% preventive service expansion
Tier 2 – Gold
$200–$499
- ✓10% premium credit
- ✓10% coverage boost
- ✓Lower PCP visit co-pay ($15)
Tier 3 – Platinum
$500–$999
- ✓15% credit
- ✓$0 deductibles for preventive prescriptions
- ✓Priority claims processing
Tier 4 – Diamond
$1,000+
- ✓20% credit
- ✓$0 PCP & mental health tele-visits
- ✓Concierge support
ELIGIBILITY REQUIREMENTS
- ✓Resident of New York State
- ✓Age 18–65
- ✓Earn income from gig / self-employed / contractor work
- ✓Maintain an active Gig Insure Wallet
- ✓Enroll during Open Enrollment or Qualifying Life Event
NETWORK
Plan C3 uses a NY State of Health–approved PPO network, allowing:
- 🌐In-network discounted care
- 🌐Nationwide out-of-network emergency coverage
- 🌐Telehealth nationwide
CLAIMS PROCESS – AI + HUMAN HYBRID
Submit claim via app
AI pre-verification
Human compliance review
Payment to provider or reimbursement
Wallet adjustment + rewards application
Standard processing time:48–72 hours
Diamond Tier:Same-day processing (when possible)
LIMITATIONS & EXCLUSIONS
- ×Non-medically necessary cosmetic procedures
- ×Services without prior authorization (when required)
- ×Non-FDA approved treatments
- ×Long-term care services
- ×Experimental therapies not covered by ACA
CANCELLATION, TERMINATION & REFUNDS
Member-Initiated Cancellation:
Refund of unused wallet funds.
Failure to maintain wallet minimum:
30-day grace period before suspension.
Non-payment after rewards applied:
The plan terminates after 60 days.
APPEALS & GRIEVANCES (NYDFS-Compliant)
Members may file:
- 📋Level 1 Internal Appeal
- 📋Level 2 External Appeal (NY State of Health)
- 📋Independent Medical Review
Resolution period:30 days standard / 72 hours expedited
REGULATORY DISCLOSURES
Gig Insure complies with:
- ⚖️Affordable Care Act (42 U.S.C. §18001 et seq.)
- ⚖️New York Insurance Law & DFS Regulations
- ⚖️NY State of Health Marketplace Standards
- ⚖️HIPAA & PHI Requirements
CONTACT INFORMATION
Gig Insure – New York Division