Services Not Covered and Co-Payments of the Healthy NY Health Insurance Plan
Services Not Covered by Healthy NY
Healthy NY offers a streamlined benefit package, which lowers premiums. Because of this, certain services are not covered. Some of these services include:
- Mental health services and prescription drugs related to mental health conditions, including treatment for depression, anxiety, and attention deficit hyperactivity disorder (ADHD)
- Alcohol and substance abuse treatment and prescription drugs related to alcohol and substance abuse treatment
- Chiropractic care
- Physical therapy, except post-surgery or post-hospitalization
- Home health care, except post-surgery or post-hospitalization
- Hospice
- Ambulance
- Dental, vision, and hearing aids
- Out-of-state treatment, unless in the case of an emergency
If a service is not covered, then your Healthy NY plan will not pay for it.
Prescription Drug Benefit
You can choose Healthy NY with or without a prescription drug benefit. The prescription drug benefit has a $3,000 per person per year benefit maximum and a $100 annual deductible.
Co-Payments and Deductibles
Most services have a co-payment. The co-payment is an amount that you must pay at the time you receive services. Co-payments are the same for each HMO.
A deductible is an amount that you must pay before your HMO will pay for services. There are no deductibles unless you choose the prescription drug plan or the high deductible health plan. More information on the high deductible health plan is on page 4.
Co-payment amounts are:
| Covered Service | Applicable Co-Payment |
| Inpatient hospital services | $500 |
| Surgical services | Lesser of 20% or $200 |
| Outpatient/ambulatory surgery center | $75 |
| Emergency room | $50 (waived if admitted to the hospital) |
| Prenatal care | $10 |
| Well-child visits/immunizations | No charge |
| All other services, including checkups, specialist visits, preventive care, diagnostic testing, and lab work | $20 |
| Optional prescription drug benefit | Maximum benefit of $3,000 per person per year - $100 deductible per calendar year - $10 co-payment for generic drugs - $20 co-payment for brand name drugs plus the difference in cost between the brand name drug and generic equivalent (if a generic exists) |
Pre-Existing Condition Limitation
Healthy NY plans are subject to a pre-existing condition limitation. This means that if you have a medical condition that you have been diagnosed with or treated for in the last 6 months, services for the treatment of that condition may be excluded from coverage for up to 12 months. However, you will still have coverage for all other covered conditions. Be aware that pregnancy is a pre-existing condition for individuals, and coverage can be excluded for up to 10 months. Pregnancy is not a pre-existing condition for sole proprietors or people with small group policies. The pre-existing condition waiting period will be reduced or eliminated if you had prior insurance and apply for Healthy NY within 63 days of your prior coverage ending. You should check with your health plan in advance to determine how this waiting period might impact coverage of your existing health conditions.
