Plan of NY

Summary of Benefits

Type of Benefit	HIP Coverage
In-patient (except behavioural health) - Unlimited days - semiprivate room & board - Hospital-provided services - Routine nursing care	$0
Out-patient - Surgery and ambulatory surgery - Pre-surgical testing (performed within 7 days of scheduled surgery) - Chemotherapy & radiation therapy - Mammography screening and cervical cancer screening	$0
Emergency Room/Facility (initial visit) - Accidental injury - Sudden and serious medical condition	$0
Ambulance	$0
Other Facility Benefits
Home Health Care - Up to 200 visits per calendar year - Home Infusion Therapy	$0
Out-patient Kidney Dialysis Home, hospital based or free-standing facility treatment	$10
Skilled Nursing Facility Up to 120 days per calendar year	$0
Hospice Up to 210 days per lifetime	$0
Physical Therapy Up to 60 in-patient days per calendar year	$0
Preventive Care Benefits
Annual Physical Exam	$0
Diagnostic Screening Test	$0
Prostrate Specific Antigen (PSA) Test	$0
Well-woman Care (no referral needed)	$0
Mammography Screening	$0
Well-child Care (including recommended immunizations) - Newborn baby 1 in-hospital exam at birth - Birth to 1 year of age 6 visits - 1 through 2 years of age 3 visits - 3 through 6 years of age 4 visits - 7 up to 19th birthday 6 visits	$0
Medical Benefits
Office or Home Visits/Office Consultations	$0
Surgery	$0
Surgical Assistant	$0
Anaesthesia	$0
In-patient Visits/Consultations	$0
Maternity Care	$0
Artificial Insemination Procedures	$0
Diagnostic X-Rays	$0
Lab Tests	$0
MRIs	$0
Cardiac Rehabilitation	$0
Second Surgical Opinion	$0
Second Medical Opinion for Cancer Diagnosis	$0
Allergy Testing and Allergy Treatment	$0
Prosthetic, Orthotic and Durable Medical Equipment	$0
Medical Supplies	$0
Therapy Benefits
Physical Therapy - 90 in-patient visits, and - 90 visits combined	$0
Occupational Speech, Vision 30 visits combined	$0
Behavioral Health Benefits
Mental Health Care	$0
Out-patient Alcohol and Substance Abuse	$0
In-patient Alcohol and Substance Abuse	$0
Alternative Benefits
Acupuncture/Yoga/Massage	Discounted rates
Chiropractic Care (no referral needed)	$0
Prescriptions
Prescription Drugs - Pharmacy	$5 for generic/brand per 30-day supply
Prescription Drugs - Mail Order Programme	$2.50 for generic/brand per 30-day supply
Vision Care Programme Through a designated group of providers	$0 for 1 exam every 12 months $45 for frames and lenses from a select group once every 24 months