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New York State Department of Financial Services

Benefit Package

Network-Based Coverage

Most of the insurance companies that offer Healthy NY are HMOs. This means that benefits are provided through each insurance company’s network of medical providers. You must use the doctors and health care providers who participate in your insurance company’s network, except in an emergency. To find out of a health care provider is in your insurance company’s network, contact the insurance company or visit the Provider Networks page.

Covered Benefits

This is not intended to be a complete list of covered benefits.  Please refer to your health plan coverage documents for a full description of covered benefits.

  • Office Visits:  Primary Care and Specialist
  • Preventive Care:  Well-Child Care, Adult Annual Physical Examinations, Adult Immunizations, Well-Woman Examinations, Mammograms, Family Planning & Reproductive Health Services, Bone Mineral Density Testing, and Screening for Prostate Cancer
  • Emergency and Urgent Care:  Ambulance Services, Emergency Department and Urgent Care Center
  • Professional Services and Outpatient Care:  Advanced Imaging Services, Allergy Testing and Treatment, Ambulatory Surgery Center, Anesthesia Services, Cardiac & Pulmonary Rehabilitation, Chemotherapy, Chiropractic Services, Diagnostic Testing, Dialysis, Habilitation Services, Home Health Care, Infertility Treatment, Infusion Therapy, Inpatient Medical Visits, Laboratory Procedures, Maternity & Newborn Care, Preadmission Testing, Diagnostic and Therapeutic Radiology Services, Rehabilitation Services, Second Opinions, Surgical Services
  • Additional Services, Equipment & Devices:  Autism Spectrum Disorder Diagnosis and Treatment, Hospice, Diabetic Equipment and  Supplies, Durable Medical Equipment and Braces, Hearing Aids, Cochlear Implants, Medical Supplies and Prosthetics
  • Inpatient Services & Facilities:  Hospital Services (including Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, and End of Life Care), Skilled Nursing Facility, and Rehabilitation Services
  • Mental Health and Substance Use Services:  Inpatient and Outpatient
  • Prescription Drugs
  • Wellness
  • Pediatric Dental & Vision

Cost Sharing 2016

Please consult your health plan coverage documents for a more extensive description of your cost sharing responsibility.  Some examples of copayments and coinsurance are included below.

Deductible

$600 individual / $1,200 family

Maximum out of pocket costs

$4,000 individual / $8,000 family

Primary Care Physician (PCP) visit

$25

Specialist visit

$40

Preventive Care

No cost sharing

Ambulance

$150

Emergency Room visit

$150 (waived if admitted)

Urgent Care

$60

Chemotherapy, radiation therapy

$25 per visit

Chiropractic care

$40

Physical therapy, occupational therapy, speech therapy

$30

Diagnostic and routine laboratory and pathology

$40

Diagnostic and routine imaging

$40

Surgical Services – inpatient, outpatient and surgicenters

$100

DME / Medical supplies

20%  coinsurance

Hearing aids

20%  coinsurance

Inpatient Facility / Skilled Nursing / Hospice

$1,000 per admission

Mental Health & Substance Use Disorder Services

$1,000 per admission (inpatient)
$25 (outpatient)

Prescription drugs
     Ask your health plan about mail order.     

$10 generic
$35 formulary brand
$70 non-formulary brand

Pediatric dental - office visit

$25

Pediatric vision – eye exam visit
    Prescribed lenses and frames or contact lenses

$25
20%  coinsurance



 

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