Benefit Package

Network-Based Coverage

The health plans that offer Healthy NY coverage have their own medical provider networks. This means that benefits are provided a 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. Contact your health plan directly to confirm whether your health care providers are in their network.

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 2020

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