New York Essential Plan cost-sharing matrix

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Marcia Strickland
6 years ago
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New York Plan cost-sharing matrix On January 1, 2016, Empire BlueCross BlueShield HealthPlus (Empire) is offering a new comprehensive and affordable health insurance program.

1 New York Plan cost-sharing matrix On January 1, 2016, Empire BlueCross BlueShield HealthPlus (Empire) is offering a new comprehensive and affordable health insurance program. The Plan is a health benefit coverage program for low- to moderate-income residents who would otherwise be ineligible to purchase coverage through the Health Insurance Marketplace or qualify for Medicaid or Child Health Plus. As an Empire provider, your continued commitment to providing quality care across all products to our members is central to helping them achieve and maintain good health. Use the below cost-sharing grid to view the differences in cost-sharing between the four Plans. Empire BlueCross BlueShield HealthPlus Plan cost-sharing Cost sharing Plan 1 Plan 2 Plan 3 Plan 4 Out-of-pocket limit $2,000 $200 $200 $0 Primary care office visits Specialist office visits (or home visits) $25 Screening for prostate cancer Performed in PCP office Performed in specialist office $25 Prehospital emergency medical services (ambulance services) $75 Nonemergency ambulance services $75 Emergency department Copayment/coinsurance waived if hospital admission $75 Urgent care center $25 Advanced imaging services or office setting $25 Performed as outpatient hospital services $25 Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus, LLC, an independent licensee of the Blue Cross and Blue Shield Association. NYEPEC

2 Page 2 of 6 Allergy testing and treatment Performed in a PCP office Performed in a specialist office $25 Ambulatory surgical center facility fee $50 Cardiac and pulmonary rehabilitation Performed in a specialist office $25 Performed as outpatient hospital services $25 Performed as inpatient hospital services Included as part of inpatient hospital service cost-sharing Chemotherapy Performed in a PCP office Performed in a specialist office Performed as outpatient hospital services Chiropractic services $25 Diagnostic testing Performed in a PCP office Performed in a specialist office $25 Performed as outpatient hospital services $25 Dialysis Performed in a PCP office Performed in a freestanding center or specialist office setting Performed as outpatient hospital services Habilitation services (Physical therapy, occupational therapy or speech therapy) 60 visits per condition, per lifetime combined therapies

3 Page 3 of 6 Home health care 40 visits per plan year Infusion therapy Performed in a PCP office Performed in specialist office Performed as outpatient hospital services Home infusion therapy (home infusion counts toward home health care visit limits) Laboratory procedures Performed in a PCP office Performed in a freestanding laboratory facility or specialist office $25 Performed as outpatient hospital services $25 Maternity and newborn care Prenatal care $0 Inpatient hospital services and birthing center $150 per admission Physician and midwife delivery $50 Breast pump $0 Postnatal care Included in physician and midwife delivery costsharing Included in physician and midwife delivery cost-sharing Included in physician and midwife delivery cost-sharing Included in physician and midwife delivery costsharing

4 Page 4 of 6 Outpatient hospital surgery facility charge $50 Diagnostic radiology services Performed in a PCP office or specialist office $25 Performed as outpatient hospital services $25 Outpatient hospital surgery facility charge $50 Diagnostic radiology services Performed in a PCP office or specialist office $25 Performed as outpatient hospital services $50 Therapeutic radiology services or specialist office Performed as outpatient hospital services Rehabilitation services (physical therapy, occupational therapy or speech therapy) (60 visits per condition, per lifetime; per plan year combined therapies) Second opinions on the diagnosis of cancer, surgery and other $25

5 Page 5 of 6 Surgical services (including oral surgery; reconstructive breast surgery; other reconstructive and corrective surgery; transplants; and interruption of pregnancy) All transplants must be performed at designated facilities. Inpatient hospital surgery $50 Outpatient hospital surgery $50 Surgery performed at an ambulatory surgical center $15 (when performed at PCP office) Office surgery $25 (when performed at specialist office) Telemedicine program $15 PCP visit $25 specialist visit ABA treatment for Autism Spectrum Disorder Assistive communication devices for Autism Spectrum Disorder Durable medical equipment and braces 5% cost-sharing External hearing aids (Single purchase; one every three years) 5% cost-sharing Cochlear implants (One 1 per ear per time covered) 5% cost-sharing Hospice care Inpatient Outpatient 210 days per plan year Five visits for family bereavement counseling Medical supplies 5% coinsurance

6 Page 6 of 6 Prosthetic devices External One (1) prosthetic device, per limb, per lifetime, and the cost of repair and replacement of the prosthetic devices and its parts 5% coinsurance Internal Included as part of inpatient hospital costsharing Inpatient hospital for a continuous confinement (including an inpatient stay for mastectomy care, cardiac and pulmonary rehabilitation, and end of life care) Observation stay Copay waived if direct transfer from outpatient surgery setting to observation $75 Skilled nursing facility (including cardiac and pulmonary rehabilitation) 200 days per plan year Copay waived for each admission if directly transferred from hospital inpatient setting to skilled nursing facility Inpatient rehabilitation services (Physical, speech and occupational therapy) 60 consecutive days per condition, per lifetime Inpatient mental health care (for a continuous confinement when in a hospital) Outpatient mental health care (including partial hospitalization and intensive outpatient program services) Inpatient substance use services (for a continuous confinement when in a hospital) Outpatient substance use services Up to 20 visits per plan year may be used for family counseling

MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold

SECTION XXIV MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold COST-SHARING Deductible Individual Family Out-of-Pocket Limit Individual Family $0 $0 $7,150 $14,300 except as required for emergency