Benefit Package

New! Changes to Healthy NY as a result of Federal Healthcare Reform
Updates to this website coming soon.

The Healthy NY benefit packages, which are streamlined, consist of health benefits that cover essential health needs including: inpatient and outpatient hospital services, physician services, maternity care, preventive health services, diagnostic and x-ray services, and emergency services. Applicants may choose a benefit package with or without a limited prescription benefit.

Benefit Package (PDF format)

Keep in Mind…

• Even though Healthy NY benefit packages are the same, the health plans may charge different premium rates.
• Once you have chosen which type of benefit package you want - with or without the prescription drug benefit - you will not be able to change your choice of benefit package until your annual recertification or if your premium rate changes.
• Covered services are subject to a copayment. All benefits are provided "in-network" only, except for emergency services or where care is not available through a health care plan’s providers. Otherwise, you must use a health care plan’s network of providers.
  

Covered Services Include the Following:

• Diagnostic screening for prostate cancer for men
• Coverage for home health care for up to 40 post-hospital or post-surgical visits in a calendar year
• Coverage for 30 post-hospital or post-surgical visits per calendar year for physical therapy
• Inpatient hospital services consisting of daily room and board, general nursing care, special diets and miscellaneous hospital services and supplies
• Outpatient hospital services consisting of diagnostic and treatment services
• Physician services consisting of diagnostic and treatment services, consultant and referral services, surgical services (including breast reconstruction surgery after a mastectomy), anesthesia services, second surgical opinion, and a second opinion for cancer treatment
• Outpatient surgical facility charges related to a covered surgical procedure
• Pre-admission testing
• Maternity care
• Adult preventive services consisting of mammography screening, cervical cytology screening, periodic physical examinations no more than once every three years, and adult immunizations
• Preventive and primary health care services for dependent children including routine well-child visits and necessary immunizations
• Equipment, supplies and self-management education for the treatment of diabetes
• Diagnostic, x-ray, and laboratory services
• Emergency services
• Therapeutic services consisting of radiological services, chemotherapy and hemodialysis
• Blood and blood products furnished in connection with surgery or inpatient hospital services

If the prescription drug benefit is selected:

• Prescription drugs obtained at a participating pharmacy ($3,000 maximum per person, per year)

Copayments and Deductibles

Covered services are subject to a copayment.  The copayment is an amount that you must pay at the time you receive services.  Copayment amounts are the same for each health plan. 

If you choose the benefit that includes prescription drug coverage, there is a $100 annual deductible for prescription drugs.  This deductible amount is the same for each health plan.

If you enroll in the Healthy NY High Deductible Health Plan Option, any money that you spend on copayments for preventive services cannot be applied towards your plan deductible.  If you enroll in the Healthy NY High Deductible Health Plan Option and you choose the prescription drug benefit, then the $100 prescription drug deductible does not apply.

The applicable copayments are:

Services Not Covered by Healthy NY

Because Healthy NY has a streamlined benefit package, certain services are not covered. Examples of those services include:

• Mental health services, including treatment and medication for ADHD, depression, and anxiety
• Alcohol and substance abuse treatment
• Chiropractic coverage
• Hospice care
• Ambulance, dental care, vision care, durable medical equipment

Pre-Existing Condition Limitation

Coverage under the Healthy NY program is subject to a pre-existing condition waiting period. This means that if the applicant has a medical condition that they have been either diagnosed with or treated for in the last six months, services for the treatment of that condition may be excluded from coverage for up to a year.

However:

• If an applicant has had prior health insurance coverage and has not had a break in coverage that is longer than 63 days, the pre-existing condition limitation waiting period will be reduced or waived.
• Coverage for other services will still be available for all other covered conditions.

Pregnancy is a pre-existing condition in individual contracts. It is not a pre-existing condition in contracts issued to sole proprietors or small employers.

Applicants should check with their health plan in advance to determine how this waiting period would impact the initial coverage of any existing health conditions they may have.