Mandated Benefits for Inclusion in Individual Direct Pay HMO Contracts

§§ 4321 & 4322

The following table provides the citations to the Insurance Law for health insurance benefits. The benefit listing is current through November 1, 2009. However, the statute must be consulted to find additional information on whether or not the benefits are mandated for inclusion in a particular type of insurance contract.

It identifies the benefits and general information on the scope of the benefit in a standardized individual direct pay contract. However, unless Insurance Law §4322(b) expressly changes the requirements, Insurance Law §4303 should be consulted for the parameters of each benefit.

Service	Scope
Inpatient hospital services	Room & board General nursing care Special diets Miscellaneous hospital services
Outpatient hospital services	Diagnostic & treatment services X-rays Laboratory tests
Physician services	Consultant & referral services, includes a second medical opinion for cancer diagnosis Primary & preventive care In-hospital medical services, includes mastectomy care Surgical services, includes mastectomy reconstruction Anesthetic services Second surgical opinion
Preventive health services	Periodic physical exams Well child care Immunizations Mammography screening Cervical cytology screening
Emergency services	Emergency medical services provided in a hospital
Diagnostic laboratory services
Radiology services	Therapeutic Diagnostic
Preadmission testing
Home health care	Up to 200 visits per calendar year
Maternity care
Chemotherapy services
Hemodialysis services
Outpatient physical therapy	Up to 90 visits per condition per calendar year
Hospice care	Up to 210 days
Skilled nursing facility care
Diabetic treatment	Equipment Supplies Education
Inpatient mental health care	30 days per calendar year (offset by chemical abuse treatment)
Outpatient mental health	Up to 30 non-emergency visits & 3 emergency visits per calendar year
Inpatient alcoholism & substance abuse	Up to 30 days per calendar year for detoxification (offset by inpatient mental health care)
Ambulance services
Private duty nursing	Up to $5,000 per calendar year; $10,000 lifetime maximum
Durable medical equipment	Prosthetics Orthotics Durable medical equipment Medical supplies
Inpatient physical rehabilitation services
Blood & blood products
Prescription drugs	Includes enteral formulas, cancer drugs, and contraceptive drugs and devices Pharmacy Mail order
Bone density measurements, testing , drugs, and devices
Experimental or investigational services recommended by an external appeal agent
End of life care**

** See Public Health Law §4406-e

Updated 10/28/2009