Silver Plan Cost Sharing Reductions Variations
- Document also available in Portable Document Format (PDF)
INDEX |
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100–150% FPL |
150–200% FPL |
200–250% FPL |
NY State of Health – Standard SILVER Plan
Cost–Sharing Reduction Variation (100–150% FPL)
Schedule of Benefits
COST–SHARING | Member Cost–Sharing Responsibility for Services from Participating Providers* |
---|---|
Deductible
Out–of–Pocket Limit
|
NONE NONE $1,000 $2,000 |
OFFICE VISITS | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits** |
---|---|---|
Primary Care Office Visits (or Home Visits) | $10 Copayment | |
Specialist Office Visits (or Home Visits) | $20 Copayment |
PREVENTIVE CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
• Well Child Visits and Immunizations* | Covered in full | |
• Adult Annual Physical Examinations* | Covered in full | |
• Adult Immunizations* | Covered in full | |
Routine Gynecological Services/Well Woman Exams* | Covered in full | |
• Mammography Screenings* | Covered in full | |
• Sterilization Procedures for Women* | Covered in full | |
• Vasectomy | $10 Copayment (PCP) $20 Copayment (Specialist) |
|
• Bone Density Testing* | Covered in full | |
• Screening for Prostate Cancer | Covered in full | |
• All other preventive services required by USPSTF and HRSA. | Covered in full | |
• *Preventive services that are provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA are covered in full. Preventive services that are provided outside of these guidelines may be subject to cost–sharing. | Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures & Diagnostic Testing) |
EMERGENCY CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Pre–Hospital Emergency Medical Services (Ambulance Services) | $50 Copayment (for services provided from both participating and non–participating providers) | |
Non–Emergency Ambulance Services | $50 Copayment Preauthorization Required |
|
Emergency Department Coinsurance waived if Hospital admission | $50 Copayment (for services provided from both participating and non–participating providers) | |
Urgent Care Center | $30 Copayment |
PROFESSIONAL SERVICES AND OUTPATIENT CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Advanced Imaging Services • Performed in a Freestanding Radiology Facility or Office Setting | $20 Copayment | |
Advanced Imaging Services • Performed as Outpatient Hospital Services | $20 Copayment Preauthorization Required |
|
Allergy Testing & Treatment | Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Surgery; Laboratory & Diagnostic Procedures) Preauthorization Required | |
Ambulatory Surgical Center Facility Fee | $25 Copayment Preauthorization Required |
|
Anesthesia Services (all settings) | Covered in Full Preauthorization Required |
|
Autologous Blood Banking | 5% Coinsurance Preauthorization Required |
|
Cardiac & Pulmonary Rehabilitation • Performed in a Specialist Office | $10 Copayment | |
Cardiac & Pulmonary Rehabilitation • Performed as Outpatient Hospital Services | $10 Copayment | |
Cardiac & Pulmonary Rehabilitation • Performed as Inpatient Hospital Services | Included as part of Inpatient Hospital Service Cost Sharing Preauthorization Required |
|
Chemotherapy • Performed in a PCP Office | $10 Copayment | |
Chemotherapy • Performed in a Specialist Office | $10 Copayment | |
Chemotherapy • Performed as Outpatient Hospital Services | $10 Copayment Preauthorization Required |
|
Chiropractic Services | $20 Copayment Preauthorization Required |
|
Diagnostic Testing • Performed in a PCP Office | $10 Copayment | |
Diagnostic Testing • Performed in a Specialist office | $20 Copayment | |
Diagnostic Testing • Performed as Outpatient Hospital Services | $20 Copayment Preauthorization Required |
|
Dialysis • Performed in a PCP Office | $10 Copayment (for services provided from both participating and non–participating providers) | Dialysis Performed by Non–Participating Providers is Covered Only Outside the Service Area and is Limited to 10 Visits Per Calendar Year |
Dialysis • Performed in a Freestanding Center or Specialist Office Setting | $10 Copayment (for services provided from both participating and non–participating providers) | |
Dialysis • Performed as Outpatient Hospital Services | $10 Copayment Preauthorization Required (for services provided from both participating and non–participating providers) | |
Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) | $15 Copayment Preauthorization Required |
60 visits per condition, per lifetime combined therapies |
Home Health Care | $10 Copayment Preauthorization Required |
40 Visits per Plan Year |
Infertility Services | Use Cost Sharing for Appropriate Service (Office Visit; Diagnostic Radiology Services; Surgery; Laboratory & Diagnostic Procedures) Preauthorization Required | |
Infusion Therapy • Performed in a PCP Office | $10 Copayment | Home Infusion counts towards Home Health Care Visit Limits |
Infusion Therapy • Performed in Specialist Office | $10 Copayment | |
Infusion Therapy • Performed as Outpatient Hospital Services | $10 Copayment | |
Infusion Therapy • Home Infusion Therapy | $10 Copayment Preauthorization Required |
|
Inpatient Medical Visits | $0 Copayment after Deductible not covered in full | |
Laboratory Procedures • Performed in a PCP Office | 50% Coinsurance after Deductible | |
Laboratory Procedures • Performed in a Freestanding Laboratory Facility or Specialist Office | $10 Copayment | |
Laboratory Procedures • Performed as Outpatient Hospital Services | $20 Copayment | |
Maternity & Newborn Care • Prenatal Care | $20 Copayment | 1 Home Care Visit is Covered at no Cost–Sharing if mother is discharged from Hospital early |
Maternity & Newborn Care • Inpatient Hospital Services and Birthing Center | Covered in Full | |
Maternity & Newborn Care • Physician and Nurse Midwife Services for Delivery | $100 per admission | |
Maternity & Newborn Care • Breast Pump | $25 Copayment | Covered for duration of breast feeding |
Outpatient Hospital Surgery Facility Charge | Covered in Full Preauthorization Required |
|
Preadmission Testing | $25 Copayment Preauthorization Required |
|
Diagnostic Radiology Services • Performed in a PCP Office | $0 Copayment Preauthorization Required |
|
Diagnostic Radiology Services • Performed in a Freestanding Radiology Facility or Specialist Office | $10 Copayment | |
Diagnostic Radiology Services • Performed as Outpatient Hospital Services | $20 Copayment | |
Therapeutic Radiology Services • Performed in a Freestanding Radiology Facility or Specialist Office | $10 Copayment | |
Therapeutic Radiology Services • Performed as Outpatient Hospital Services | $10 Copayment Preauthorization Required |
|
Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) | $15 Copayment Preauthorization Required |
60 visits per condition, per lifetime combined therapies Speech and Physical Therapy are only Covered following a Hospital stay or surgery. |
Second Opinions on the Diagnosis of Cancer, Surgery & Other | $20 Copayment | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Inpatient Hospital Surgery | $25 Copayment | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Outpatient Hospital Surgery | $25 Copayment | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Surgery Performed at an Ambulatory Surgical Center | $25 Copayment | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Office Surgery | $20 Copayment (Specialist) $10 Copayment (PCP) Preauthorization Required |
ADDITIONAL SERVICES, EQUIPMENT & DEVICES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
ABA Treatment for Autism Spectrum Disorder | $10 Copayment Preauthorization Required |
680 Hours Per Plan Year |
Assistive Communication Devices for Autism Spectrum Disorder | $10 Copayment | |
Diabetic Equipment, Supplies & Self–Management Education • Diabetic Equipment, Supplies and Insulin (30–Day Supply) | $10 Copayment | |
Diabetic Equipment, Supplies & Self–Management Education • Diabetic Education | $10 Copayment Preauthorization Required |
|
Durable Medical Equipment & Braces | 5% Coinsurance Preauthorization Required for Items Above $100 |
|
External Hearing Aids | 5% Coinsurance Preauthorization Required |
Single Purchase Once Every 3 Years |
Cochlear Implants | 5% Coinsurance Preauthorization Required |
One Per Ear Per Time Covered |
Hospice Care • Inpatient | $100 per admission | 210 Days per Plan Year 5 Visits for Family Bereavement Counseling |
Hospice Care • Outpatient | $10 Copayment | |
Medical Supplies | 5% Coinsurance Preauthorization Required for Items Above $100 |
|
Prosthetic Devices • External | 5% Coinsurance | One prosthetic device, per limb, per lifetime |
Prosthetic Devices • Internal | 5% Coinsurance Preauthorization Required |
Unlimited |
INPATIENT SERVICES & FACILITIES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Inpatient Hospital for a Continuous Confinement (Including an Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, & End of Life Care) | $100 per admission Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
|
Observation Stay | $50 Copayment Preauthorization Required |
|
Skilled Nursing Facility (Includes Cardiac & Pulmonary Rehabilitation) | $100 per admission Preauthorization Required |
200 Days Per Plan Year |
Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy) | $100 per admission Preauthorization Required |
60 Consecutive Days Per Condition, Per Lifetime |
MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Inpatient Mental Health Care (for a continuous confinement when in a Hospital) | $100 Copayment Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
|
Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) | $10 Copayment | |
Inpatient Substance Use Services (for a continuous confinement when in a Hospital) | $100 Copayment Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
|
Outpatient Substance Use Services | $10 Copayment after Deductible | Unlimited; Up to 20 Visits a Plan Year May Be Used For Family Counseling |
PRESCRIPTION DRUGS | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Retail Pharmacy 30 Day Supply Tier 1 Tier 2 Tier 3 |
$6 Copayment $15 Copayment $30 Copayment |
Member Cost–Sharing Responsibility for Services from Participating Providers | Limits | |
---|---|---|
Gym Reimbursement | Up to $200 per 6–month period; up to an additional $100 per 6–month period for Spouse, not subject to Deductible | Up to $200 per 6–month period; up to an additional $100 per 6–month period for Spouse |
PEDIATRIC DENTAL &VISION CARE*** | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Pediatric Dental Care • Preventive/Routine Dental Care |
$10 Copayment | One Dental Exam & Cleaning Per 6 Month Period |
Pediatric Dental Care • Major Dental (Endodontics & Prosthodontics) |
$10 Copayment Orthodontia & Major Dental Require Preauthorization |
|
Pediatric Dental Care • Orthodontia |
$10 Copayment Orthodontia & Major Dental Require Preauthorization |
|
Pediatric Vision Care • Exams |
$10 Copayment | One Exam Per 12–Month Period; One Prescribed Lenses & Frames in a 12 Month Period |
Pediatric Vision Care • Lenses & Frames |
5% Coinsurance | |
Pediatric Vision Care • Contact Lenses |
5% Coinsurance Contact Lenses Require Preauthorization |
|
*NOTE: Unless otherwise noted, non–participating provider services are not covered and you pay the full cost | ||
**NOTE: Additional limits may apply. Complete benefit descriptions are available from insurers upon effectuation of coverage. | ||
***NOTE: Not all Standard Plans offer Pediatric Dental Benefits. A Stand–Alone Dental Plan may need to be purchased to receive these benefits. Please refer to the plan details on our website to see if this is included or discuss further with a navigator, broker, or customer service representative. |
|top of section| |top of page|
NY State of Health – Standard SILVER Plan
Cost–Sharing Reduction Variation (150–200% FPL)
Schedule of Benefits
COST–SHARING | Member Cost–Sharing Responsibility for Services from Participating Providers |
---|---|
Deductible
Out–of–Pocket Limit
|
$250 $500 $2,000 $4,000 |
OFFICE VISITS | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits** |
---|---|---|
Primary Care Office Visits (or Home Visits) | $15 Copayment after Deductible | |
Specialist Office Visits (or Home Visits) | $35 Copayment after Deductible |
PREVENTIVE CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
• Well Child Visits and Immunizations* | Covered in full | |
• Adult Annual Physical Examinations* | Covered in full | |
• Adult Immunizations* | Covered in full | |
Routine Gynecological Services/Well Woman Exams* | Covered in full | |
• Mammography Screenings* | Covered in full | |
• Sterilization Procedures for Women* | Covered in full | |
• Vasectomy | $15 Copayment (PCP) $35 Copayment (Specialist) |
|
• Bone Density Testing* | Covered in full | |
• Screening for Prostate Cancer | Covered in full | |
• All other preventive services required by USPSTF and HRSA. | Covered in full | |
• *Preventive services that are provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA are covered in full. Preventive services that are provided outside of these guidelines may be subject to cost–sharing. | Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures & Diagnostic Testing) |
EMERGENCY CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Pre–Hospital Emergency Medical Services (Ambulance Services) | $75 Copayment after Deductible (for services provided from both participating and non–participating providers) | |
Non–Emergency Ambulance Services | $75 Copayment after Deductible Preauthorization Required | |
Emergency Department Coinsurance waived if Hospital admission | $75 Copayment after Deductible (for services provided from both participating and non–participating providers) | |
Urgent Care Center | $50 Copayment after Deductible |
PROFESSIONAL SERVICES AND OUTPATIENT CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Advanced Imaging Services • Performed in a Freestanding Radiology Facility or Office Setting | $35 Copayment after Deductible | |
Advanced Imaging Services • Performed as Outpatient Hospital Services | $35 Copayment after Deductible Preauthorization Required |
|
Allergy Testing & Treatment | Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Surgery; Laboratory & Diagnostic Procedures) Preauthorization Required | |
Ambulatory Surgical Center Facility Fee | $75 Copayment after Deductible Preauthorization Required |
|
Anesthesia Services (all settings) | Covered in Full Preauthorization Required |
|
Autologous Blood Banking | 10% Coinsurance after Deductible Preauthorization Required |
|
Cardiac & Pulmonary Rehabilitation • Performed in a Specialist Office | $15 Copayment after Deductible | |
Cardiac & Pulmonary Rehabilitation • Performed as Outpatient Hospital Services | $15 Copayment after Deductible | |
Cardiac & Pulmonary Rehabilitation • Performed as Inpatient Hospital Services | Included as part of Inpatient Hospital Service Cost Sharing Preauthorization Required |
|
Chemotherapy • Performed in a PCP Office | $15 Copayment after Deductible | |
Chemotherapy • Performed in a Specialist Office | $15 Copayment after Deductible | |
Chemotherapy • Performed as Outpatient Hospital Services | $15 Copayment after Deductible Preauthorization Required |
|
Chiropractic Services | $35 Copayment after Deductible Preauthorization Required |
|
Diagnostic Testing • Performed in a PCP Office | $15 Copayment after Deductible | |
Diagnostic Testing • Performed in a Specialist office | $35 Copayment after Deductible | |
Diagnostic Testing • Performed as Outpatient Hospital Services | $35 Copayment after Deductible Preauthorization Required |
|
Dialysis • Performed in a PCP Office | $15 Copayment (for services provided from both participating and non–participating providers) | Dialysis Performed by Non–Participating Providers is Covered Only Outside the Service Area and is Limited to 10 Visits Per Calendar Year |
Dialysis • Performed in a Freestanding Center or Specialist Office Setting | $15 Copayment after Deductible (for services provided from both participating and non–participating providers) | |
Dialysis • Performed as Outpatient Hospital Services | $15 Copayment after Deductible Preauthorization Required (for services provided from both participating and non– participating providers) | |
Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) | $25 Copayment after Deductible Preauthorization Required |
60 visits per condition, per lifetime combined therapies |
Home Health Care | $15 Copayment after Deductible Preauthorization Required |
40 Visits per Plan Year |
Infertility Services | Use Cost Sharing for Appropriate Service (Office Visit; Diagnostic Radiology Services; Surgery; Laboratory & Diagnostic Procedures) Preauthorization Required | |
Infusion Therapy • Performed in a PCP Office | $15 Copayment after Deductible | Home Infusion counts towards Home Health Care Visit Limits |
Infusion Therapy • Performed in Specialist Office | $15 Copayment after Deductible | |
Infusion Therapy • Performed as Outpatient Hospital Services | $15 Copayment after Deductible | |
Infusion Therapy • Home Infusion Therapy | $15 Copayment after Deductible Preauthorization Required |
|
Inpatient Medical Visits | $0 Copayment after Deductible not covered in full | |
Laboratory Procedures • Performed in a PCP Office | $15 Copayment after Deductible | |
Laboratory Procedures • Performed in a Freestanding Laboratory Facility or Specialist Office | $35 Copayment after Deductible | |
Laboratory Procedures • Performed as Outpatient Hospital Services | $35 Copayment after Deductible | |
Maternity & Newborn Care • Prenatal Care | Covered in Full | 1 Home Care Visit is Covered at no Cost–Sharing if mother is discharged from Hospital early |
Maternity & Newborn Care • Inpatient Hospital Services and Birthing Center | $250 per admission after Deductible | |
Maternity & Newborn Care • Physician and Nurse Midwife Services for Delivery | $75 Copayment after Deductible | |
Maternity & Newborn Care • Breast Pump | Covered in Full Preauthorization Required |
Covered for duration of breast feeding |
Outpatient Hospital Surgery Facility Charge | $75 Copayment after Deductible Preauthorization Required |
|
Preadmission Testing | $0 Copayment after Deductible Preauthorization Required |
|
Diagnostic Radiology Services • Performed in a PCP Office | $15 Copayment after Deductible | |
Diagnostic Radiology Services • Performed in a Freestanding Radiology Facility or Specialist Office | $35 Copayment after Deductible | |
Diagnostic Radiology Services • Performed as Outpatient Hospital Services | $35 Copayment after Deductible Preauthorization Required |
|
Therapeutic Radiology Services • Performed in a Freestanding Radiology Facility or Specialist Office | $15 Copayment after Deductible | |
Therapeutic Radiology Services • Performed as Outpatient Hospital Services | $15 Copayment after Deductible Preauthorization Required |
|
Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) | $25 Copayment after Deductible Preauthorization Required |
60 visits per condition, per lifetime combined therapies Speech and Physical Therapy are only Covered following a Hospital stay or surgery. |
Second Opinions on the Diagnosis of Cancer, Surgery & Other | $35 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Inpatient Hospital Surgery | $75 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Outpatient Hospital Surgery | $75 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Surgery Performed at an Ambulatory Surgical Center | $75 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Office Surgery | $35 Copayment after Deductible (Specialist) $15 Copayment after Deductible (PCP) Preauthorization Required |
ADDITIONAL SERVICES, EQUIPMENT & DEVICES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
ABA Treatment for Autism Spectrum Disorder | $15 Copayment after Deductible Preauthorization Required |
680 Hours Per Plan Year |
Assistive Communication Devices for Autism Spectrum Disorder | $15 Copayment after Deductible | |
Diabetic Equipment, Supplies & Self–Management Education • Diabetic Equipment, Supplies and Insulin (30–Day Supply) | $15 Copayment after Deductible | |
Diabetic Equipment, Supplies & Self–Management Education • Diabetic Education | $15 Copayment after Deductible Preauthorization Required |
|
Durable Medical Equipment & Braces | 10% Coinsurance after Deductible Preauthorization Required for Items Above $100 |
|
External Hearing Aids | 10% Coinsurance after Deductible Preauthorization Required |
Single Purchase Once Every 3 Years |
Cochlear Implants | 10% Coinsurance after Deductible Preauthorization Required |
One Per Ear Per Time Covered |
Hospice Care • Inpatient | $250 per admission after Deductible | 210 Days per Plan Year 5 Visits for Family Bereavement Counseling |
Hospice Care • Outpatient | $15 Copayment after Deductible | |
Medical Supplies | 10% Coinsurance after Deductible Preauthorization Required |
|
Prosthetic Devices • External | 10% Coinsurance after Deductible | One prosthetic device, per limb, per lifetime |
Prosthetic Devices • Internal | 10% Coinsurance after Deductible Preauthorization Required |
Unlimited |
INPATIENT SERVICES & FACILITIES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Inpatient Hospital for a Continuous Confinement (Including an Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, & End of Life Care) | $250 per admission after Deductible Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
|
Observation Stay | $75 Copayment after Deductible Preauthorization Required |
|
Skilled Nursing Facility (Includes Cardiac & Pulmonary Rehabilitation) | $250 per admission after Deductible Preauthorization Required |
200 Days Per Plan Year |
Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy) | $250 per admission after Deductible Preauthorization Required |
60 Consecutive Days Per Condition, Per Lifetime |
MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Inpatient Mental Health Care (for a continuous confinement when in a Hospital) | $250 Copayment after Deductible Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
|
Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) | $15 Copayment after Deductible | |
Inpatient Substance Use Services (for a continuous confinement when in a Hospital) | $250 Copayment after Deductible Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
|
Outpatient Substance Use Services | $15 Copayment after Deductible | Unlimited; Up to 20 Visits a Plan Year May Be Used For Family Counseling |
PRESCRIPTION DRUGS | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Retail Pharmacy 30 Day Supply Tier 1 Tier 2 Tier 3 |
$9 Copayment $20 Copayment $40 Copayment |
Member Cost–Sharing Responsibility for Services from Participating Providers | Limits | |
---|---|---|
Gym Reimbursement | Up to $200 per 6–month period; up to an additional $100 per 6–month period for Spouse, not subject to Deductible | Up to $200 per 6–month period; up to an additional $100 per 6–month period for Spouse |
PEDIATRIC DENTAL &VISION CARE*** | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Pediatric Dental Care • Preventive/Routine Dental Care |
$15 Copayment after Deductible | One Dental Exam & Cleaning Per 6 Month Period |
Pediatric Dental Care • Major Dental (Endodontics & Prosthodontics) |
$15 Copayment after Deductible Orthodontia & Major Dental Require Preauthorization |
|
Pediatric Dental Care • Orthodontia |
$15 Copayment after Deductible Orthodontia & Major Dental Require Preauthorization |
|
Pediatric Vision Care • Exams |
$15 Copayment after Deductible | One Exam Per 12–Month Period; One Prescribed Lenses & Frames in a 12 Month Period |
Pediatric Vision Care • Lenses & Frames |
10% Coinsurance after Deductible | |
Pediatric Vision Care • Contact Lenses |
10% Coinsurance after Deductible Contact Lenses Require Preauthorization | |
*NOTE: Unless otherwise noted, non–participating provider services are not covered and you pay the full cost | ||
**NOTE: Additional limits may apply. Complete benefit descriptions are available from insurers upon effectuation of coverage. | ||
***NOTE: Not all Standard Plans offer Pediatric Dental Benefits. A Stand–Alone Dental Plan may need to be purchased to receive these benefits. Please refer to the plan details on our website to see if this is included or discuss further with a navigator, broker, or customer service representative. |
|top of section| |top of page|
NY State of Health – Standard SILVER Plan
Cost–Sharing Reduction Variation (200–250% FPL)
Schedule of Benefits
COST–SHARING | Member Cost–Sharing Responsibility for Services from Participating Providers |
---|---|
Deductible
Out–of–Pocket Limit
|
$1,750 $3,500 $4,000 $8,000 |
OFFICE VISITS | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits** |
---|---|---|
Primary Care Office Visits (or Home Visits) | $30 Copayment after Deductible | |
Specialist Office Visits (or Home Visits) | $50 Copayment after Deductible |
PREVENTIVE CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
• Well Child Visits and Immunizations* | Covered in full | |
• Adult Annual Physical Examinations* | Covered in full | |
• Adult Immunizations* | Covered in full | |
Routine Gynecological Services/Well Woman Exams* | Covered in full | |
• Mammography Screenings* | Covered in full | |
• Sterilization Procedures for Women* | Covered in full | |
• Vasectomy | $30 Copayment after Deductible (PCP) | |
$50 Copayment after Deductible (Specialist) | ||
• Bone Density Testing* | Covered in full | |
• Screening for Prostate Cancer | Covered in full | |
• All other preventive services required by USPSTF and HRSA. | Covered in full | |
• *Preventive services that are provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA are covered in full. Preventive services that are provided outside of these guidelines may be subject to cost–sharing. | Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures & Diagnostic Testing) |
EMERGENCY CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Pre–Hospital Emergency Medical Services (Ambulance Services) | $150 Copayment after Deductible (for services provided from both participating and non–participating providers) | |
Non–Emergency Ambulance Services | $150 Copayment after Deductible Preauthorization Required |
|
Emergency Department Coinsurance waived if Hospital admission | $150 Copayment after Deductible (for services provided from both participating and non–participating providers) | |
Urgent Care Center | $70 Copayment after Deductible |
PROFESSIONAL SERVICES AND OUTPATIENT CARE | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Advanced Imaging Services • Performed in a Freestanding Radiology Facility or Office Setting | $50 Copayment after Deductible | |
Advanced Imaging Services • Performed as Outpatient Hospital Services | $50 Copayment after Deductible Preauthorization Required |
|
Allergy Testing & Treatment | Use Cost Sharing for Appropriate Service (Primary Care Office Visit; Specialist Office Visit; Surgery; Laboratory & Diagnostic Procedures) Preauthorization Required | |
Ambulatory Surgical Center Facility Fee | $100 Copayment after Deductible Preauthorization Required |
|
Anesthesia Services (all settings) | Covered in Full Preauthorization Required |
|
Autologous Blood Banking | 25% Coinsurance after Deductible Preauthorization Required |
|
Cardiac & Pulmonary Rehabilitation • Performed in a Specialist Office | $30 Copayment after Deductible | |
Cardiac & Pulmonary Rehabilitation • Performed as Outpatient Hospital Services | $30 Copayment after Deductible | |
Cardiac & Pulmonary Rehabilitation • Performed as Inpatient Hospital Services | Included as part of Inpatient Hospital Service Cost Sharing Preauthorization Required |
|
Chemotherapy • Performed in a PCP Office | $30 Copayment after Deductible | |
Chemotherapy • Performed in a Specialist Office | $30 Copayment after Deductible | |
Chemotherapy • Performed as Outpatient Hospital Services | $30 Copayment after Deductible Preauthorization Required |
|
Chiropractic Services | $50 Copayment after Deductible Preauthorization Required |
|
Diagnostic Testing • Performed in a PCP Office | $30 Copayment after Deductible | |
Diagnostic Testing • Performed in a Specialist office | $50 Copayment after Deductible | |
Diagnostic Testing • Performed as Outpatient Hospital Services | $50 Copayment after Deductible Preauthorization Required |
|
Dialysis • Performed in a PCP Office | $30 Copayment after Deductible (for services provided from both participating and non–participating providers) | Dialysis Performed by Non–Participating Providers is Covered Only Outside the Service Area and is Limited to 10 Visits Per Calendar Year |
Dialysis • Performed in a Freestanding Center or Specialist Office Setting | $30 Copayment after Deductible (for services provided from both participating and non–participating providers) | |
Dialysis • Performed as Outpatient Hospital Services | $30 Copayment after Deductible Preauthorization Required (for services provided from both participating and non– participating providers) | |
Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) | $30 Copayment after Deductible Preauthorization Required |
60 visits per condition, per lifetime combined therapies |
Home Health Care | $30 Copayment after Deductible Preauthorization Required |
40 Visits per Plan Year |
Infertility Services | Use Cost Sharing for Appropriate Service (Office Visit; Diagnostic Radiology Services; Surgery; Laboratory & Diagnostic Procedures) Preauthorization Required | |
Infusion Therapy • Performed in a PCP Office | $30 Copayment after Deductible | Home Infusion counts towards Home Health Care Visit Limits |
Infusion Therapy • Performed in Specialist Office | $30 Copayment after Deductible | |
Infusion Therapy • Performed as Outpatient Hospital Services | $30 Copayment after Deductible | |
Infusion Therapy • Home Infusion Therapy | $30 Copayment after Deductible Preauthorization Required |
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Inpatient Medical Visits | $0 Copayment after Deductible not covered in full | |
Laboratory Procedures • Performed in a PCP Office | $30 Copayment after Deductible | |
Laboratory Procedures • Performed in a Freestanding Laboratory Facility or Specialist Office | $50 Copayment after Deductible | |
Laboratory Procedures • Performed as Outpatient Hospital Services | $50 Copayment after Deductible | |
Maternity & Newborn Care • Prenatal Care | Covered in Full | 1 Home Care Visit is Covered at no Cost–Sharing if mother is discharged from Hospital early |
Maternity & Newborn Care • Inpatient Hospital Services and Birthing Center | $1,500 per admission after Deductible | |
Maternity & Newborn Care • Physician and Nurse Midwife Services for Delivery | $100 Copayment after Deductible | |
Maternity & Newborn Care • Breast Pump | Covered in Full Preauthorization Required |
Covered for duration of breast feeding |
Outpatient Hospital Surgery Facility Charge | $100 Copayment after Deductible Preauthorization Required |
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Preadmission Testing | $0 Copayment after Deductible Preauthorization Required |
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Diagnostic Radiology Services • Performed in a PCP Office | $30 Copayment after Deductible | |
Diagnostic Radiology Services • Performed in a Freestanding Radiology Facility or Specialist Office | $50 Copayment after Deductible | |
Diagnostic Radiology Services • Performed as Outpatient Hospital Services | $50 Copayment after Deductible Preauthorization Required |
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Therapeutic Radiology Services • Performed in a Freestanding Radiology Facility or Specialist Office | $30 Copayment after Deductible | |
Therapeutic Radiology Services • Performed as Outpatient Hospital Services | $30 Copayment after Deductible Preauthorization Required |
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Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) | $30 Copayment after Deductible Preauthorization Required |
60 visits per condition, per lifetime combined therapies Speech and Physical Therapy are only Covered following a Hospital stay or surgery. |
Second Opinions on the Diagnosis of Cancer, Surgery & Other | $50 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Inpatient Hospital Surgery | $100 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Outpatient Hospital Surgery | $100 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Surgery Performed at an Ambulatory Surgical Center | $100 Copayment after Deductible | |
Surgical Services (Including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) • Office Surgery | $50 Copayment after Deductible (Specialist) $30 Copayment after Deductible (PCP) Preauthorization Required |
ADDITIONAL SERVICES, EQUIPMENT & DEVICES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
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ABA Treatment for Autism Spectrum Disorder | $30 Copayment after Deductible Preauthorization Required |
680 Hours Per Plan Year |
Assistive Communication Devices for Autism Spectrum Disorder | $30 Copayment after Deductible | |
Diabetic Equipment, Supplies & Self–Management Education • Diabetic Equipment, Supplies and Insulin (30–Day Supply) | $30 Copayment after Deductible | |
Diabetic Equipment, Supplies & Self–Management Education • Diabetic Education | $30 Copayment after Deductible Preauthorization Required |
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Durable Medical Equipment & Braces | 25% Coinsurance after Deductible Preauthorization Required for Items Above $100 |
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External Hearing Aids | 25% Coinsurance after Deductible Preauthorization Required |
Single Purchase Once Every 3 Years |
Cochlear Implants | 25% Coinsurance after Deductible Preauthorization Required |
One Per Ear Per Time Covered |
Hospice Care • Inpatient | $1,500 per admission after Deductible | 210 Days per Plan Year 5 Visits for Family Bereavement Counseling |
Hospice Care • Outpatient | $30 Copayment after Deductible | |
Medical Supplies | 25% Coinsurance after Deductible Preauthorization Required |
|
Prosthetic Devices • External | 25% Coinsurance after Deductible | One prosthetic device, per limb, per lifetime |
Prosthetic Devices • Internal | 25% Coinsurance after Deductible Preauthorization Required |
Unlimited |
INPATIENT SERVICES & FACILITIES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Inpatient Hospital for a Continuous Confinement (Including an Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, & End of Life Care) | $1,500 per admission after Deductible Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
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Observation Stay | $150 Copayment after Deductible Preauthorization Required |
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Skilled Nursing Facility (Includes Cardiac & Pulmonary Rehabilitation) | $1,500 per admission after Deductible Preauthorization Required |
200 Days Per Plan Year |
Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy) | $1,500 per admission after Deductible Preauthorization Required |
60 Consecutive Days Per Condition, Per Lifetime |
MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Inpatient Mental Health Care (for a continuous confinement when in a Hospital) | $1,500 Copayment after Deductible Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
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Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) | $30 Copayment after Deductible | |
Inpatient Substance Use Services (for a continuous confinement when in a Hospital) | $1,500 Copayment after Deductible Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. |
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Outpatient Substance Use Services | $30 Copayment after Deductible | Unlimited; Up to 20 Visits a Plan Year May Be Used For Family Counseling |
PRESCRIPTION DRUGS | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Retail Pharmacy 30 Day Supply Tier 1 Tier 2 Tier 3 |
$10 Copayment after Deductible $35 Copayment after Deductible $70 Copayment after Deductible |
Member Cost–Sharing Responsibility for Services from Participating Providers | Limits | |
---|---|---|
Gym Reimbursement | Up to $200 per 6–month period; up to an additional $100 per 6–month period for Spouse, not subject to Deductible | Up to $200 per 6–month period; up to an additional $100 per 6–month period for Spouse |
PEDIATRIC DENTAL &VISION CARE*** | Member Cost–Sharing Responsibility for Services from Participating Providers | Limits |
---|---|---|
Pediatric Dental Care • Preventive/Routine Dental Care |
$30 Copayment after Deductible | One Dental Exam & Cleaning Per 6 Month Period |
Pediatric Dental Care • Major Dental (Endodontics & Prosthodontics) |
$30 Copayment after Deductible Orthodontia & Major Dental Require Preauthorization |
|
Pediatric Dental Care • Orthodontia |
$30 Copayment after Deductible Orthodontia & Major Dental Require Preauthorization |
|
Pediatric Vision Care • Exams |
$30 Copayment after Deductible | One Exam Per 12–Month Period; One Prescribed Lenses & Frames in a 12 Month Period |
Pediatric Vision Care • Lenses & Frames |
25% Coinsurance after Deductible | |
Pediatric Vision Care • Contact Lenses |
25% Coinsurance after Deductible Contact Lenses Require Preauthorization | |
*NOTE: Unless otherwise noted, non–participating provider services are not covered and you pay the full cost | ||
**NOTE: Additional limits may apply. Complete benefit descriptions are available from insurers upon effectuation of coverage. | ||
***NOTE: Not all Standard Plans offer Pediatric Dental Benefits. A Stand–Alone Dental Plan may need to be purchased to receive these benefits. Please refer to the plan details on our website to see if this is included or discuss further with a navigator, broker, or customer service representative. |
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