Description of Services |
In-Network |
Out-of--Network |
| 365 days of semi-private room & board in an acute care hospital* |
Covered in full |
Base Hospital Coverage: Up to 100% of reasonable & customary allowed amount |
| Hospital Deductible |
None |
None |
| Hospital Coinsurance |
None |
None |
| Maternity* |
Covered in full |
Base Hospital Coverage |
| Routine Nursery Care |
Covered in full |
Base Hospital Coverage |
| Outpatient Emergency Care (facility charges) |
Covered in full |
Base Hospital Coverage |
| Freestanding Ambulatory Surgery Center Care* |
Covered in full |
Base Hospital Coverage |
| Pre-Admission Testing - no more than 7 days before scheduled surgery |
|
Base Hospital Coverage |
Inpatient Psychiatric Care*
30 days per calendar year. Counts toward the 365 day hospital max. |
Covered in full |
Base Hospital Coverage |
Outpatient Psychiatric*
Care 20 visits per calendar year. |
Covered in full |
Base Hospital Coverage |
| Inpatient Substance Abuse Treatment per calendar year* |
Covered in full up to 30 days for detox & rehabilitation combined. Counts toward the 365 day hospital max. |
Not covered |
| Outpatient Substance Abuse Treatment - 60 visits per person, per calendar year (imp to 20 of these may be used for family therapy)* |
Covered in full |
Base Hospital Coverage |
| Outpatient Hospital-Based and Free-Standing Facility Dialysis |
Covered in full |
Base Hospital Coverage |
| Inpatient Admissions for Physical Therapy, Physical Medicine & Rehabilitation per calendar year* |
Covered in full up to 30 days. Counts towards the 365 hospital max. |
Not covered |
| Diagnostic Admissions |
Not covered |
Not covered |
| Home Care Visits - Up to 40 visits per person, per calendar year* |
Covered in full |
Base Hospital Coverage |
| Hospice Care - 210 days per lifetime (includes 5 bereavement counseling sessions for family members) |
Covered in full |
Base Hospital Coverage |
| Skilled Nursing Facility Care |
Not covered |
Not covered |
| Managed Care - including Precertification, Voluntary Second Surgical Opinion and Large Case Management (LCM) |
Yes |
Yes |
| Centers of Specialized Care - Paid-in-full benefits for select cardiac procedures and heart transplants |
Not covered |
Not covered |
| Outpatient Referred Ambulatory Care: laboratory tests, physical therapy, diagnostic X-rays and radiation therapy and chemotherapy |
Not covered |
Not covered |
| Outpatient Mammography Screening and Pap Smear Screening |
Covered |
Base Hospital Coverage |
| Air Ambulance |
Not covered |
Not covered |
| Dependent Children Coverage |
Covered under age 23 |
Covered under age 23 |
| Dependent Student Coverage |
Covered under age 23 |
Covered under age 23 |
*Indicates these services may be subject to Pre-certification.
| |
Monthly Rates |
| New York City |
|
| Individual |
117.05 |
| Medicare Carve-Out |
52.67 |
| Employee and Child(ren) |
191.75 |
| Employee and Spouse |
266.00 |
| Employee, Spouse and Child(ren) |
279.65 |
| Mid-Hudson |
|
| Individual |
106.78 |
| Medicare Carve-Out |
48.05 |
| Employee and Child(ren) |
174.98 |
| Employee and Spouse |
242.73 |
| Employee, Spouse and Child(ren) |
255.20 |
| Albany |
|
| Individual |
99.38 |
| Medicare Carve-Out |
44.70 |
| Employee and Child(ren) |
162.90 |
| Employee and Spouse |
225.97 |
| Employee, Spouse and Child(ren) |
237.59 |
| Utica/Watertown |
|
| Individual |
82.14 |
| Medicare Carve-Out |
36.96 |
| Employee and Child(ren) |
134.67 |
| Employee and Spouse |
186.79 |
| Employee, Spouse and Child(ren) |
196.38 |
| Syracuse |
|
| Individual |
92.27 |
| Medicare Carve-Out |
41.52 |
| Employee and Child(ren) |
151.24 |
| Employee and Spouse |
209.82 |
| Employee, Spouse and Child(ren) |
220.58 |
| Rochester |
|
| Individual |
94.09 |
| Medicare Carve-Out |
42.36 |
| Employee and Child(ren) |
154.19 |
| Employee and Spouse |
213.88 |
| Employee, Spouse and Child(ren) |
224.85 |
| Buffalo |
|
| Individual |
94.09 |
| Medicare Carve-Out |
42.36 |
| Employee and Child(ren) |
154.19 |
| Employee and Spouse |
213.88 |
| Employee, Spouse and Child(ren) |
224.85 |
