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Small Business Eligibility

Benefit Package

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Who Can be Covered

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Employers and Employees

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 Directories page.

Covered Benefits 2014

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.

Cost Sharing 2014

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.


$600 individual / $1,200 family

Maximum out of pocket costs

$4,000 individual / $8,000 family

Primary Care Physician (PCP) visit


Specialist visit


Preventive Care

No cost sharing



Emergency Room visit

$150 (waived if admitted)

Urgent Care


Chemotherapy, radiation therapy

$25 per visit

Chiropractic care


Physical therapy, occupational therapy, speech therapy


Diagnostic and routine laboratory and pathology


Diagnostic and routine imaging


Surgical Services – inpatient, outpatient and surgicenters


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


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

20%  coinsurance

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