Silver Plan Cost Sharing Reductions Variations

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INDEX
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
  • Individual
  • Family

Out–of–Pocket Limit
  • Individual
  • Family


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
  • Individual
  • Family

Out–of–Pocket Limit
  • Individual
  • Family


$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
  • Individual
  • Family


Out–of–Pocket Limit
  • Individual
  • Family


$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
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
 
Preadmission Testing $0 Copayment after Deductible
Preauthorization Required
 
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
 
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
 
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
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
 
Durable Medical Equipment & Braces 25% Coinsurance after Deductible
Preauthorization Required for Items Above $100
 
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.
 
Observation Stay $150 Copayment after Deductible
Preauthorization Required
 
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.
 
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.
 
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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