Small Business

Benefit Package


Benefit Package

Network-Based Coverage

The health plans that offer Healthy NY coverage have their own medical provider networks. This means that benefits are provided a network of medical providers. You must use the doctors and health care providers who participate in your insurance company’s network, except in an emergency. Contact your health plan directly to confirm whether your health care providers are in their network.

Covered Benefits

This is not intended to be a complete list of covered benefits.  Please refer to your health plan coverage documents for a full description of covered benefits.

  • Office Visits:  Primary Care and Specialist
  • Preventive Care:  Well-Child Care, Adult Annual Physical Examinations, Adult Immunizations, Well-Woman Examinations, Mammograms, Family Planning & Reproductive Health Services, Bone Mineral Density Testing, and Screening for Prostate Cancer
  • Emergency and Urgent Care:  Ambulance Services, Emergency Department and Urgent Care Center
  • Professional Services and Outpatient Care:  Advanced Imaging Services, Allergy Testing and Treatment, Ambulatory Surgery Center, Anesthesia Services, Cardiac & Pulmonary Rehabilitation, Chemotherapy, Chiropractic Services, Diagnostic Testing, Dialysis, Habilitation Services, Home Health Care, Infertility Treatment, Infusion Therapy, Inpatient Medical Visits, Laboratory Procedures, Maternity & Newborn Care, Preadmission Testing, Diagnostic and Therapeutic Radiology Services, Rehabilitation Services, Second Opinions, Surgical Services
  • Additional Services, Equipment & Devices:  Autism Spectrum Disorder Diagnosis and Treatment, Hospice, Diabetic Equipment and  Supplies, Durable Medical Equipment and Braces, Hearing Aids, Cochlear Implants, Medical Supplies and Prosthetics
  • Inpatient Services & Facilities:  Hospital Services (including Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, and End of Life Care), Skilled Nursing Facility, and Rehabilitation Services
  • Mental Health and Substance Use Services:  Inpatient and Outpatient
  • Prescription Drugs
  • Wellness
  • Pediatric Dental & Vision

Cost Sharing 2020

Please consult your health plan coverage documents for a more extensive description of your cost sharing responsibility.  Some examples of copayments and coinsurance are included below.


$600 individual / $1,200 family

Maximum out of pocket costs

$4,000 individual / $8,000 family

Primary Care Physician (PCP) visit


Specialist visit


Preventive Care

No cost sharing



Emergency Room visit

$150 (waived if admitted)

Urgent Care


Chemotherapy, radiation therapy

$25 per visit

Chiropractic care


Physical therapy, occupational therapy, speech therapy


Diagnostic and routine laboratory and pathology


Diagnostic and routine imaging


Surgical Services – inpatient, outpatient and surgicenters


DME / Medical supplies

20%  coinsurance

Hearing aids

20%  coinsurance

Inpatient Facility / Skilled Nursing / Hospice

$1,000 per admission

Mental Health & Substance Use Disorder Services

$1,000 per admission (inpatient)
$25 (outpatient)

Prescription drugs
     Ask your health plan about mail order.     

$10 generic
$35 formulary brand
$70 non-formulary brand

Pediatric dental - office visit


Pediatric vision – eye exam visit
    Prescribed lenses and frames or contact lenses

20%  coinsurance