Individuals and Sole Proprietors

Benefit Package

The Healthy NY benefit package includes important services such as hospital care and doctors' office visits. You may also choose an optional prescription drug benefit. Although many different insurance companies offer Healthy NY, each insurance company offers the same standardized benefit package. Insurance companies have different premiums and provider networks. You can change benefit packages at the time of annual recertification or if there is a change in the premium rate.

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 Directories page.

Covered Benefits

• Adult screening services including annual mammogram, annual Pap test, annual prostate cancer screening, adult immunizations and routine physical examinations once every three years
• Preventive services for children including routine well-child visits and immunizations
• Inpatient hospital services including daily room and board, general nursing care, special diets and miscellaneous hospital services and supplies
• Outpatient hospital services including diagnostic and treatment services and surgical facility charges
• Physician services including diagnostic, treatment, consultant and referral services
• Surgical services including anesthesia, pre-admission testing and breast reconstruction surgery after a mastectomy
• Emergency services (ambulance not covered)
• Second opinion for surgical and cancer treatment
• Diagnostic, X-ray and laboratory services
• Radiation, chemotherapy and hemodialysis
• Maternity and prenatal care
• Home health care (up to 40 post-hospital or post-surgical visits per calendar year)
• Physical therapy (up to 30 post-hospital or post-surgical visits per calendar year)
• Diabetes equipment, supplies and self-management education
• Therapeutic services including radiological services, chemotherapy and hemodialysis
• Blood and blood products furnished in connection with surgery or inpatient hospital services
• Optional prescription drug benefit

PDF list of covered benefits and copayments

Copayments and Deductibles

Except for preventive services, most services have a copayment.  The copayment is an amount that you must pay at the time you receive services.  Copayment amounts are the same for each insurance company. A deductible is the amount you must pay before your insurance company will pay for services.  All Healthy NY coverage with an effective date of January 1, 2012 or later is subject to an annual deductible of $1,250 for an individual and $2,500 for a family.  For more information on deductibles, please visit our page on High Deductible Health Plans (HDHPs). Some services (such as preventive services) are not subject to the deductible.

Services Not Covered by Healthy NY

Because Healthy NY has a streamlined benefit package, certain services are not covered.

Examples of these services include:

• Mental health services and prescription drugs relating to mental health conditions, including but not limited to treatment and medication for ADHD, depression and anxiety
• Alcohol and substance abuse treatment
• Chiropractic coverage
• Hospice care
• Ambulance
• Dental, vision and hearing aids
• Durable medical equipment, prosthetics, orthotics and supplies