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Core Health mandated benefits in New York

TA | August 24, 2008

Q: Does Core Health Insurance include the benefits mandated under New York state law?

A: New York Core Health policies include the following extra benefits:

MANDATED BENEFITS Cancer Screening - mammograms, pap smears & prostate cancer screenings are payable on the same basis as any other diagnostic test under the policy. For example, if the policy pays $50 per sitting or draw, then $50 would be payable for each test. As the policy limits the number of sittings or draw per policy year, the cancer screening would be paid in addition to that limit. For example, if the policy had a limit of 5 sittings or draws, and the person had used all 5 for sickness, they would still be paid a $50 benefit for a mammogram. If the cancer screening was billed less than the $50, then we would not exceed the amount billed. These benefits are stated under the DIAGNOSTIC TESTS, X-RAYS, and LABORATORY BENEFIT in the first paragraph. They are not in a separate section. Doctor Visits - Newborn Well-Care & Immunizations - the doctor visits are payable on a per day basis while hospital confined. Payment for doctor visits outpatient are payable for newborn well care. If the child has used all the visits for sickness or injury, they still would be entitled to newborn well care visits. The cost of the immunizations are payable as billed. Benefits are payable for cancer second opinion, post-natal parent education and diabetes self-management training. These would not reduce the number of benefits payable for injury or sickness. Home Health - home health is payable in lieu of hospital confinement at the benefit level shown in the policy. Mental, Nervous, Emotional, Biologically Based Mental, Children w/ Serious Emotional Disturbances - MNE must be paid for 30 days inpatient at the inpatient benefit level in the policy & 20 days of "active treatment" which is outpatient. The person may trade two partial hospitalization days for one full hospitalization days. The Bio and SED must be paid as any other sickness and these benefits would be paid on top of what they may have used up for sickness or injury. Chiropractic Care Expense - a chiropractor will be paid for a doctor visit as any other doctor, x-rays will be paid as any other sickness. In addition, they are paid the Treatment benefit amount for the actual treatment (subluxation). The benefits available for treatment are shown on the schedule. Diabetes - the policy must cover the testing and supplies equipment for the treatment of diabetes. The benefit amount is shown on the schedule. End of Life Care Expense - this is specific to persons diagnosed as dying of cancer. It has a 60-day maximum. The amount of per day of the benefit is shown on the schedule. THIS IS LIMITED INDEMNITY COVERAGE. IT IS NOT MAJOR MEDICAL COVERAGE and is not intended to replace other medical coverage. There is a 30-day waiting period for Sickness A 12-month Pre-existing Condition Limitation applies to the following benefits: Hospital, including First Day Admission, Hospital Standard room, Intensive Care/Cardiac Care Unit, Surgery and Anesthesia.

These benefits are included in addition to the benefits available in other states. Please see Exclusions and Limitations. Underwritten by United States Fire Insurance Company.


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